Association of peripheral artery disease and chronic limb-threatening ischemia with socioeconomic deprivation in people with diabetes: A population data-linkage and geospatial analysis.

The association between the prevalence and geographical distribution of peripheral artery disease (PAD) and chronic limb-threatening ischemia (CLTI) in patients with diabetes in the context of socioeconomic deprivation is not well understood. We undertook a retrospective cohort study of 76,307 people with diabetes admitted as a hospital inpatient in a large Scottish health administrative area. Utilising linked health records, we identified diagnoses of PAD and/or CLTI and their distribution using small area cartography techniques according to multiple deprivation maps. Spatial autocorrelation techniques were applied to examine PAD and CLTI patterning. Association between crude inpatient prevalence-adjusted outcome rates and exposure to social deprivation were determined. We found crude prevalence-adjusted rates of 8.05% for PAD and 1.10% for CLTI with a five- to sevenfold difference from the least to most deprived regions. Statistically significant hot spots were found for PAD (p < 0.001) and CLTI (p < 0.001) in the most deprived areas, and cold spots for PAD (p < 0.001) but not CLTI (p = 0.72) in the least deprived areas. Major health disparities in PAD/CLTI diagnoses in people with diabetes is driven by socioeconomic deprivation.

Geospatial mapping and data linkage uncovers variability in outcomes of foot disease according to multiple deprivation: a population cohort study of people with diabetes.

AIMS/HYPOTHESIS: Our aim was to investigate the geospatial distribution of diabetic foot ulceration (DFU), lower extremity amputation (LEA) and mortality rates in people with diabetes in small geographical areas with varying levels of multiple deprivation. METHODS: We undertook a population cohort study to extract the health records of 112,231 people with diabetes from the Scottish Care Information - Diabetes Collaboration (SCI-Diabetes) database. We linked this to health records to identify death, LEA and DFU events. These events were geospatially mapped using multiple deprivation maps for the geographical area of National Health Service (NHS) Greater Glasgow and Clyde. Tests of spatial autocorrelation and association were conducted to evaluate geographical variation and patterning, and the association between prevalence-adjusted outcome rates and multiple deprivation by quintile. RESULTS: Within our health board region, people with diabetes had crude prevalence-adjusted rates for DFU of 4.6% and for LEA of 1.3%, and an incidence rate of mortality preceded by either a DFU or LEA of 10.5 per 10,000 per year. Spatial autocorrelation identified statistically significant hot spot (high prevalence) and cold spot (low prevalence) clusters for all outcomes. Small-area maps effectively displayed near neighbour clustering across the health board geography. Disproportionately high numbers of hot spots within the most deprived quintile for DFU (p < 0.001), LEA (p < 0.001) and mortality (p < 0.001) rates were found. Conversely, a disproportionately higher number of cold spots was found within the least deprived quintile for LEA (p < 0.001). CONCLUSIONS/INTERPRETATION: In people with diabetes, DFU, LEA and mortality rates are associated with multiple deprivation and form geographical neighbourhood clusters.

The future for diabetic foot ulcer prevention: A paradigm shift from stratified healthcare towards personalized medicine.

Prevention of diabetic foot ulcers is important to reduce the burden of diabetic foot disease. However, we found that ulcer prevention is underexposed in research and clinical practice. Barriers to explain this are seen in patient's goal-setting; in the lack of interdisciplinary teams for ulcer prevention; in sample sizes and funding for research; in industrial engagement; and in limited understanding of ulcer development. Rather than separately solving these barriers, we propose a paradigm shift from stratified healthcare towards personalized medicine for diabetic foot disease. Personalized medicine aims to deliver the right treatment to the right patient at the right time, based on individual diagnostics. Different treatment strategies should be available for different patients, delivered in an integrated, objective, quantitative and evidence-based approach. More than on the classical risk factors of peripheral neuropathy and peripheral artery disease, individual diagnostics should focus on modifiable risk factors for ulceration. This includes structured biomechanical and behavioral profiling, while new research with (big) data science may identify additional risk factors, such as geographical or temporal patterns in ulceration. Industry involvement can drive the development of wearable instruments and assessment tools, to facilitate large-scale individual diagnostics. For a paradigm shift towards personalized medicine in prevention, large-scale collaborations between stakeholders are needed. As each ulcer episode not prevented costs about €10,000 in medical costs alone, such investments can be cost-effective. We hope to see more discussions around this paradigm shift, and increasing investments of energy and money in diabetic foot ulcer prevention in research and clinical practice.

Metatarsal Loading During Gait-A Musculoskeletal Analysis.

Detailed knowledge of the loading conditions within the human body is essential for the development and optimization of treatments for disorders and injuries of the musculoskeletal system. While loads in the major joints of the lower limb have been the subject of extensive study, relatively little is known about the forces applied to the individual bones of the foot. The objective of this study was to use a detailed musculoskeletal model to compute the loads applied to the metatarsal bones during gait across several healthy subjects. Motion-captured gait trials and computed tomography (CT) foot scans from four healthy subjects were used as the inputs to inverse dynamic simulations that allowed the computation of loads at the metatarsal joints. Low loads in the metatarsophalangeal (MTP) joint were predicted before terminal stance, however, increased to an average peak of 1.9 times body weight (BW) before toe-off in the first metatarsal. At the first tarsometatarsal (TMT) joint, loads of up to 1.0 times BW were seen during the early part of stance, reflecting tension in the ligaments and muscles. These loads subsequently increased to an average peak of 3.0 times BW. Loads in the first ray were higher compared to rays 2-5. The joints were primarily loaded in the longitudinal direction of the bone.

Metatarsophalangeal joint pain in psoriatic arthritis: a cross-sectional study.

OBJECTIVE: The aim of this study was to identify independent predictors of pain at the MTP joints in patients with PsA. METHODS: Thirty-four consecutive patients with PsA (mean age 45.3 years, 65% female, mean disease duration 9.9 years) and 22 control participants (mean age 37.9 years, 64% female) underwent clinical and US examination to determine the presence of pain, swelling, synovitis, erosions, effusions and submetatarsal bursae at the MTP joints. Mean barefoot peak plantar pressures were determined at each MTP joint. Levels of pain, US-determined pathology and peak pressures were compared between groups. Binary logistic regression was used to identify demographic, clinical examination-derived, US-derived and plantar pressure predictors of pain at the MTP joints in the PsA group. RESULTS: The presence of pain, deformity, synovitis, erosions (P < 0.001) and submetatarsal bursae and peak plantar pressure at MTP 3 (P < 0.05) were significantly higher in the PsA group. MTP joint pain in PsA was independently predicted by high BMI, female gender and the presence of joint subluxation, synovitis and erosion. CONCLUSION: These results suggest local inflammatory and structural factors, together with systemic factors (gender, BMI), are predominantly responsible for painful MTP joints in PsA, with no clear role for plantar pressure characteristics.

Kinematic, kinetic and electromyographic response to customized foot orthoses in patients with tibialis posterior tenosynovitis, pes plano valgus and rheumatoid arthritis.

OBJECTIVE: To describe the effect of customized foot orthoses (FOs) on the kinematic, kinetic and EMG features in patients with RA, tibialis posterior (TP) tenosynovitis and associated pes plano valgus. METHODS: Patients with RA and US-confirmed tenosynovitis of TP underwent gait analysis, including three-dimensional (3D) kinematics, kinetics, intramuscular EMG of TP and surface EMG of tibialis anterior, peroneus longus, soleus and medial gastrocnemius. Findings were compared between barefoot and shod with customized FO conditions. RESULTS: Ten patients with RA with a median (range) disease duration of 3 (1-18) years were recruited. Moderate levels of foot pain and foot-related impairment and disability were present with moderately active disease states. Altered timing of the soleus (P = 0.05) and medial gastrocnemius (P = 0.02) and increased magnitude of tibialis anterior (P = 0.03) were noted when barefoot was compared with shod with FO. Trends were noted for reduced TP activity in the contact period (P = 0.09), but this did not achieve statistical significance. Differences in foot motion characteristics were recorded for peak rearfoot eversion (P = 0.01), peak rearfoot plantarflexion (P < 0.001) and peak forefoot abduction (P = 0.02) in the shod with FOs compared with barefoot conditions. No differences in kinetic variables were recorded. CONCLUSION: This study has demonstrated, for the first time, alterations in muscle activation profiles and foot motion characteristics in patients with RA, pes plano valgus and US-confirmed TP tenosynovitis in response to customized FOs. Complex adaptations were evident in this cohort and further work is required to determine whether these functional alterations lead to improvements in patient symptoms.

Room for improvement: patient, parent, and practitioners' perceptions of foot problems and foot care in juvenile idiopathic arthritis.

OBJECTIVE: To explore the perceived impact of disease-related foot problems and foot care in juvenile idiopathic arthritis (JIA) from the perspectives of patients, parents, pediatric rheumatologists, and health professionals. DESIGN: A qualitative study using an interpretative phenomenological approach. SETTING: Outpatients department, public health service children's hospital. PARTICIPANTS: Patients (N=15; 4 adult patients, 2 parents of children with JIA, 3 pediatric rheumatologists, and 6 health professionals) from 2 National Health Service rheumatology centers (1 pediatric and 1 adult). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Qualitative outcomes were participants' perceptions elicited using semistructured interviews (telephone or face-to-face) and focus groups using an interpretative phenomenological approach. A data-driven inductive approach to coding and theme development was adopted for transcript analysis. RESULTS: Participants volunteered to take part in a total of 7 interviews and 2 focus groups. The analysis revealed 6 key themes related to the impact of foot problems and perceptions of foot care from respective groups. These were the following: (1) pain, (2) mobility impairment, (3) reduced ability to perform activities of daily living, (4) footwear difficulties, (5) poor referral pathways/delayed access to care, and (6) lack of evidence in support of conservative foot care. CONCLUSIONS: Several areas for development of foot care services were identified including a need for improved referral pathways, shorter waiting times for initial consultations, greater attention to patient compliance, and a need for better evidence in support of customized foot orthoses. Several key foot health-related outcomes were identified, which may be of importance for measuring therapeutic response to foot-related interventions.

The effect of foot orthoses on gait biomechanics and pain among people with rheumatoid arthritis: A quasi-experimental study.

BACKGROUND: Foot pain is frequent among people with rheumatoid arthritis (RA). Foot orthoses (FO) are commonly prescribed with the intention to reduce pain symptoms and improve function. RESEARCH QUESTION: How do a custom-made FO affect pain, gait biomechanics and daily activity among people with RA? METHODS: Twenty-five participants with RA and foot pain completed this quasi-experimental study using a control insole for four weeks and then a custom-made FO in the following four weeks. The foot orthoses were customized by plantar foot shape targeting optimal restoration of normal arch height. A visual analog scale was used to monitor changes in ankle/foot, knee, hip joints, and global arthritis pain. In addition, the perceived pain area was measured using a body chart analysis. Kinematics and kinetics of the hip, knee and ankle joints during gait were analyzed using 3D-motion capture. Daily steps were measured with a wrist-based activity tracker for both the control insole and custom-made FO period, respectively. RESULTS: In comparison to the control insole, the custom-made FO reduced ankle/foot pain intensity (p < 0.001) in addition to a reduction of the perceived pain areas in the feet (p < 0.001), legs (p = 0.012), as well as the arms and hands (p = 0.014). Ankle plantar flexion and eversion moments were also reduced (p < 0.001). No difference in daily steps was observed between the two periods (p = 0.657). SIGNIFICANCE: This study has demonstrated an ankle/foot pain-relieving effect in conjunction with alterations of the ankle joint moments in people with RA using custom-made FO. The pain relief is plausibly attributed to alterations of the ankle joint moments when using the custom-made FO. However, future studies are needed to explore further into therapeutic implication of custom-made FO in pain management of people with RA.

Different types of foot orthoses effect on gait mechanics in patients with rheumatoid arthritis.

Foot orthoses are a first line conservative treatment for foot impairments in patients with rheumatoid arthritis (RA), however their effect on gait mechanics is poorly understood. We aimed to compare changes in lower limb and foot mechanics between two types of commonly used foot orthoses (FO) with a control. Twenty-seven patients with rheumatoid arthritis participated in this crossover study. Two different types of FO (a medially wedged custom-made FO and a prefabricated FO with a metatarsal dome, respectively), were compared against a control insole. During gait, lower limb mechanics were analyzed using 3D motion capture, force plates, and an in-shoe pressure system. Inverse dynamics models were created in the Anybody Modeling System to calculate joint angles and joint moments during gait. Gait variables were analyzed using statistical parametric mapping. Compared to the control, the prefabricated FO had limited effect on gait mechanics. Compared to the control the custom-made FO reduced ankle plantarflexion moment with 0.4 %body weight * body height (BW * BH) between 66 and 76% of stance and ankle eversion moment was reduced 0.16% BW*BH between 3 and 40% of stance. Furthermore, it also reduced the average forefoot plantar pressure by 9 kPa between 20 and 62% of stance compared to the control. Changes in foot pressure distribution, joint moments and angles were most pronounced for custom-made FO compared to the prefabricated FO. The findings suggest that patients with RA and foot impairments may benefit more from an individualized FO strategy, if the aim of the treatment is to alter gait mechanics. (NCT03561688).

Rasch analysis of Dutch-translated version of the Foot Impact Scale for rheumatoid arthritis.

OBJECTIVE: To translate the foot impact scale for RA (FIS-RA) to the dutch target language and to evaluate its internal construct validity using rasch analysis. METHODS: Forward and backward translations of the original English version of the FIS-RA scale, combined with synthesis techniques and expert committee review, were undertaken to produce a final Dutch version with two subscales for impairment/footwear (FIS-RA(IF)) and activity/participation (FIS-RA(AP)). The pre-final version was field tested in RA patients to investigate face and content validity. FIS-RA questionnaires were completed by 207 Dutch RA patients. Rasch analysis tested the data for overall fit to the model, item and person fit, unidimensionality, differential item function (DIF) by age, gender and disease duration, targeting, reliability and local response dependency. Item deletion and re-analysis were planned, where Rasch model assumptions were violated. RESULTS: The FIS-RA(IF) (P < 0.0001) and FIS-RA(AP) (P < 0.0001) subscales did not fit the overall Rasch model. Misfitting items, DIF by age, gender and disease duration, and local response dependency were observed in both subscales. Item thresholds showed good coverage over both scales although a floor effect was observed for the FIS-RA(AP) subscale. The person separation index was 0.81 and 0.92 for the FIS-RA(IF) and FIS-RA(AP) subscales, respectively. Both subscales were not unidimensional. Item deletion and repeat Rasch analysis produced two subscales that fitted the Rasch model and were unidimensional. CONCLUSION: A Dutch language version of the FIS-RA questionnaire was successfully developed using Rasch analysis. Subscales for impairment/footwear and activity/participation showed good construct validity and were unidimensional.

Plantar soft tissues and Achilles tendon thickness and stiffness in people with diabetes: a systematic review.

BACKGROUND: Diabetes mellitus is associated with changes in soft tissue structure and function. However, the directionality of this change and the extent to which either tissue thickness or stiffness contributes to the pathogenesis of diabetes-related foot ulcerations is unclear. Hence, this systematic review aims to summarise the existing evidence for soft tissue structural differences in the feet of people with and without diabetes. METHODS: In compliance with MOOSE and PRISMA guidelines, AMED, CINAHL, MEDLINE, ProQuest Health & Medical Collection, ProQuest Nursing & Allied Health Database, and Web of Science electronic databases were systematically searched for studies published from database inception until 1st October 2020 [Prospero CRD42020166614]. Reference lists of included studies were further screened. Methodological quality was appraised using a modified critical appraisal tool for quantitative studies developed by McMaster University. RESULTS: A total of 35 non-randomised observational studies were suitable for inclusion. Within these, 20 studies evaluated plantar tissue thickness, 19 studies evaluated plantar tissue stiffness, 9 studies evaluated Achilles tendon thickness and 5 studies evaluated Achilles tendon stiffness outcomes. No significant differences in plantar tissue thickness were found between people with and without diabetes in 55% of studies (11/20), while significantly increased plantar tissue stiffness was found in people with diabetes in 47% of studies (9/19). Significantly increased Achilles tendon thickness was found in people with diabetes in 44% of studies (4/9), while no significant differences in Achilles tendon stiffness were found between people with and without diabetes in 60% of studies (3/5). CONCLUSIONS: This systematic review found some evidence of soft tissue structural differences between people with and without diabetes. However, uncertainty remains whether these differences independently contribute to diabetes-related foot ulcerations. The heterogeneity of methodological approaches made it difficult to compare across studies and methodological quality was generally inadequate. High-quality studies using standardised and validated assessment techniques in well-defined populations are required to determine more fully the role of structural tissue properties in the pathogenesis of diabetes-related foot ulcerations.

Measuring Inflammatory Foot Disease in Rheumatoid Arthritis: Development and Validation of the Rheumatoid Arthritis Foot Disease Activity Index-5.

OBJECTIVE: Omission of foot joints from composite global disease activity indices may lead to underestimation of foot and overall disease in rheumatoid arthritis (RA) and under-treatment. The aim of this study was to evaluate the measurement properties of the Rheumatoid Arthritis Foot Disease Activity Index-5 (RADAI-F5), a newly developed patient-reported outcome measure for capturing foot disease activity in people with RA. METHODS: Participants with RA self-completed the RADAI-F5, modified Rheumatoid Arthritis Disease Activity Index (mRADAI-5), Foot Function Index (FFI), and Foot Impact Scale (FIS) impairment/footwear and activity/participation subscales. The 28-joint Disease Activity Score using the erythrocyte sedimentation rate (DAS28-ESR) was also recorded. Subgroups completed the RADAI-F5 at 1 week and 6 months. Psychometric properties, including construct, content and longitudinal validity, internal consistency, 1-week reproducibility, and responsiveness over 6 months were evaluated. RESULTS: Of 142 respondents, 103 were female, with a mean ± SD age of 55 ± 12.5 years and median RA disease duration of 10 (interquartile range 3.6-20.8) months. Theoretically consistent associations confirming construct validity were observed with mRADAI-5 (0.789 [95% confidence interval (95% CI) 0.73, 0.85]), FFI (0.713 [95% CI 0.62, 0.79]), FIS impairment/footwear (0.695 [95% CI 0.66, 0.82], P < 0.001), FIS activity/participation (0.478 [95% CI 0.37, 0.63], P < 0.001), and the DAS28-ESR (0.379 [95% CI 0.26, 0.57], P < 0.001). The RADAI-F5 demonstrated high internal consistency (Cronbach's α = 0.90) and good reproducibility (intraclass correlation coefficient = 0.868 [95% CI 0.80, 0.91], P < 0.001, smallest detectable change = 2.69). Content validity was confirmed, with 82% rating the instrument relevant and easy to understand. CONCLUSION: The RADAI-F5 is a valid, reliable, responsive, clinically feasible patient-reported outcome measure for measuring foot disease activity in RA.

Sex- and osteoarthritis-related differences in muscle co-activation during weight-bearing tasks.

BACKGROUND: Individuals with knee osteoarthritis (OA) demonstrate impairments in muscle function (i.e. muscle weakness, high muscle co-activation believed to have detrimental effects on joint integrity). Women with knee OA exhibit poorer health outcomes than men. Sex and muscle function are known risk factors for knee OA. It is unclear how these risk factors are associated with muscle function in knee OA and the implications for disease aetiology. RESEARCH QUESTION: How does sex and knee osteoarthritis disease status relate to muscle function, specifically strength and muscle co-activation, during walking, stair negotiation and sit-to-walk activities. METHODS: A cross-sectional study assessed muscle co-activation in 77 individuals with knee OA (mean[SD], 62.5[8.1] years; 48/29 women/men) and 18 age-matched controls (62.5[10.4] years; 9/9 women/men), during a series of walking, stair ascent and descent and sit-to-walk activities. Muscle strength of the knee extensors and flexors was assessed using maximal voluntary isometric contractions (MVIC). Electromyography was recorded from the vastus lateralis/medalis, rectus femoris, biceps femoris, semitendinosus, medial/lateral gastrocnemius normalised to MVIC. Multiple regression assessed the relationship between sex, disease status, and muscle strength on muscle co-activation. RESULTS: Individuals with knee OA were weaker than controls, had higher hamstrings-quadriceps and medial-lateral co-activation for specific phases of gait. Women were weaker than men with higher muscle co-activation across all activities. Sex and muscle weakness, but not age or disease status predicted high muscle co-activation. SIGNIFICANCE: High muscle co-activation was associated with female sex and muscle weakness regardless of disease status and age. High muscle co-activation is believed to be a compensatory mechanism for muscle weakness to maintain a certain level of function. High muscle co-activation is also thought to have detrimental effects on cartilage and joint integrity this may explain high muscle co-activation in women with muscle weakness and contribute to increased risk of incidence and progression of knee OA in women.

Muscle Co-Activation Across Activities of Daily Living in Individuals With Knee Osteoarthritis.

OBJECTIVE: Muscle co-activation has been shown to be elevated in individuals with knee osteoarthritis (OA) during gait. Comparisons of muscle co-activation across different activities of daily living such as stair negotiation have yet to be explored. The aim of this study was to explore muscle co-activation across different activities of daily living in patients with knee OA. METHODS: Muscle co-activation was assessed in 77 symptomatic knee OA patients (mean ± SD age 62.5 ± 8.1 years, body mass index 29.4 ± 6.0 kg/m2 , and sex 48:29 female:male) using electromyography (EMG), during a series of walking, stair negotiation (ascent, descent), and sit-to-walk activities. EMG was recorded from 7 sites, mediolateral gastrocnemius, biceps femoris, semitendinosus, vastus lateralis/medialis, and rectus femoris, and normalized to maximal voluntary isometric contraction. Correlation was used to assess the consistency of co-activation across activities. Repeated-measures analysis of variance assessed the muscle combination by activity differences. RESULTS: Muscle co-activation was highest during stair ascent. When comparing muscle combinations within the same activity, we found that correlations ranged from r = 0.003 to r = 0.897, of which 80% of the combinations were significant. Between activities, muscle co-activation was significantly different (P < 0.05). Mediolateral muscle co-activation was higher than hamstrings/quadriceps across activities. CONCLUSION: Two muscle co-activation strategies were observed during activities of daily living in patients with knee OA to maintain stability. Muscle co-activation was higher during more challenging activities, particularly when the joint was accepting load. Mediolateral muscle co-activation was higher than hamstrings/quadriceps, so that mediolateral co-activation was thought to be a stabilization mechanism, while hamstrings/quadriceps co-activation responds to knee flexion moments, suggesting that different muscle combinations may have different roles in responding to joint demand.

Characterising the clinical and biomechanical features of severely deformed feet in rheumatoid arthritis.

PURPOSE: Foot deformity is a well-recognised impairment in patients with rheumatoid arthritis (RA) which results in functional disability. Deformity can occur at the rearfoot, midfoot, forefoot or in combination and the impact that site-specific foot deformities has on functional disability is largely unknown. The aim of this study was to describe the clinical and biomechanical characteristics of patients with severe rearfoot, forefoot or combined deformities and determine localised disease impact. METHODS: Twenty-eight RA patients with severe forefoot (FF group n=12), rearfoot (RF group n=10) or combined deformities (COMB group n=6) were recruited. Each patient underwent 3D gait analysis and plantar pressure measurements. Localised disease impact and foot-specific disease activity were determined using the Leeds Foot Impact Scale and clinical examination respectively. Comparison was made against a normative control group (n=53). RESULTS: Patients in the COMB group walked slowest and the double-support time was longer in the RF and COMB groups compared to those in the FF group. Patients in the RF and COMB group had higher levels of foot-related disability and demonstrated excessive rearfoot eversion and midfoot collapse compared to those in the FF group. Forefoot deformity was associated with reduced toe contact, high forefoot pressures and delayed heel lift. CONCLUSIONS: Abnormal gait patterns were identified and were distinguishable among those patients with predominantly forefoot, rearfoot or combined foot deformity.

Methodological considerations for a randomised controlled trial of podiatry care in rheumatoid arthritis: lessons from an exploratory trial.

BACKGROUND: Whilst evidence exists to support the use of single treatments such as orthoses and footwear, the effectiveness of podiatry-led care as a complex intervention for patients with rheumatoid arthritis (RA) related foot problems is unknown. The aim of this study was to undertake an exploratory randomised controlled parallel arm clinical trial (RheumAFooT) to inform the design and implementation of a definitive trial and to understand the potential benefits of this care. METHODS: Patients with a definite diagnosis of RA, stable drug management 3 months prior to entry, and a current history of foot problems (pain, deformity, stiffness, skin or nail lesions, or footwear problems) were recruited from a hospital outpatient rheumatology clinic and randomised to receive 12 months of podiatry treatment or no care. The primary outcome was change in foot health status using the impairment/footwear (LFISIF) and activity limitation/participation restriction (LFISAP) subscales of the Leeds Foot Impact Scale. Disease Activity Score (DAS), Health Assessment Questionnaire (HAQ) score and walking speed (m/s) were also recorded. RESULTS: Of the 80 patients identified, 64 patients were eligible to participate in the pilot and 34 were recruited. 16 patients were randomised to receive podiatry led foot care and 18 received no care. Against a backdrop of stable disease (DAS and HAQ scores), there was a statistically significant between group difference in the change in foot health status for foot impairment (LFISIF) but not activity/participation (LFISAP) or function (walking speed) over 12 months. In the podiatry arm, 1 patient declined treatment following randomisation (did not want additional hospital visits) and 3 self-withdrew (lost to follow-up). Patients received an average of 3 consultations for assessment and treatment comprising routine care for skin and nail lesions (n = 3), foot orthoses (n = 9), footwear referral to the orthotist (n = 5), and ultrasound guided intra-articular steroid injection (n = 1). CONCLUSION: In this exploratory trial patients were difficult to recruit (stable drug management and co-morbid disease) and retain (lack of benefit/additional treatment burden) but overall the intervention was safe (no adverse reactions). Twelve months of podiatry care maintained but did not improve foot health status. These observations are important for the design and implementation of a definitive randomised controlled trial. TRIAL REGISTRATION: ISRCTN: 01982076.

Quality of care in the retail health care setting using national clinical guidelines for acute pharyngitis.

Rates of adherence to an acute pharyngitis practice guideline in the retail clinic setting were measured as an indicator of clinical quality. An analysis of 57,331 patient visits for the evaluation of acute pharyngitis was conducted. In 39,530 patients with a negative rapid strep test result, nurse practitioner and physician assistant staff adhered to guidelines in 99.05% of cases by withholding unnecessary antibiotics. Of 13,471 patients with a positive rapid strep test result, 99.75% received an appropriate antibiotic prescription. The combined guideline adherence rate for groups with positive and negative rapid strep test results was 99.15%. Strep cultures were performed on 99.1% of patients with a negative rapid strep test result, and 96.2% of patients with a positive culture were treated with an antibiotic. Finally, 0.95% of patients with a negative rapid strep test result were provided an antibiotic outside clinical guidelines; however, approximately half of these prescriptions (n = 190) were supported by documentation of clinical concerns for which an antibiotic was a reasonable choice.

Regionalised centre of pressure analysis in patients with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis patients alter their gait pattern to compensate for painful foot symptoms. The centre of pressure may be a useful indicator of these altered loading patterns. Our purpose was to undertake a comparison of the regionalised duration and velocity of the centre of pressure between rheumatoid arthritis patients with foot impairments and healthy able-bodied adults. METHODS: The progression of the centre of pressure through the foot, heel, midfoot, forefoot and toe regions was measured using an EMED-ST pressure platform. Patients walked at self selected cadence. Variables analysed were the average and maximum velocity and the duration of the centre of pressure (as % stance). RESULTS: In comparison with able-bodied adults, rheumatoid arthritis patients had a statistically significant decrease in the average velocity of the centre of pressure in the total foot (P<0.001), heel (P=0.001) and midfoot (P<0.001) regions. The maximum velocity of the centre of pressure was slower in rheumatoid arthritis patients in only the midfoot region (P=0.002). During stance, the duration of the centre of pressure was longer in the midfoot (P<0.001) and shorter in the forefoot (P=0.001) in the rheumatoid arthritis patients. INTERPRETATION: Alteration of the foot loading patterns in patients with rheumatoid arthritis can be characterised by changes to the centre of pressure patterns. Off-loading the painful and deformed forefoot was a characteristic feature in this patient cohort.

Prevalence, impact and care of foot problems in people with rheumatoid arthritis: results from a United Kingdom based cross-sectional survey.

BACKGROUND: Foot symptoms in rheumatoid arthritis (RA) derive from a combination of inflammation, altered foot mechanics, deformity and secondary skin lesions. Guidelines recommend regular review of patients' feet, but the extent to which the general population of RA patients report foot symptoms and access foot care has not been established. The aims of this study were to determine the prevalence, impact and care of foot problems in all patients with RA in one geographical area and identify factors associated with accessing foot care. METHODS: Cross-sectional survey of a random sample of patients with RA, who resided within a single community-based National Health Service (NHS) podiatry service. The questionnaire collected demographic data (age, gender, local deprivation score), clinical data (disease duration, arthritis medications, disability (Health Assessment Questionnaire (HAQ)), current foot problems, foot care accessed (podiatry, orthotics and/or orthopaedics) and care received, measures of impact (Foot Impact Scale) and ability to work. RESULTS: Of 1003 total eligible patients in the target population, 739 were posted survey packs. Of these 413 (56%) replied. Responders and non-responders had similar age (63.5 yr. vs.61.5 yr), gender (74.1%F vs. 75.2%F), and highest deprivation category (13.3% vs.15.9%). Of the responders 92.1% reported current foot problems: articular 73.8%, cutaneous lesions 65.4%, structural 57.6%, extra-articular 42.6%. Responders' median (IQR) disease duration 10 (5-20) years, HAQ 1.5 (0.75-2.0), FISIF 10 (6-14) and FISAP 16 (7-23) and 37.8% reported impacts on work. While 69.5% had accessed foot care there were differences in the route of access (by gender and whether independent or NHS provision) and were older (64.9 yr. vs 60.4 yr. p = 0.001), had longer disease duration (12 yr. vs 7 yr. p < 0.001) and had a greater proportion of females (72.2% vs 61.7% p = 0.04) than those who had not accessed care. CONCLUSIONS: Current foot problems were reported by 92.1% of the study sample and substantially impacted on life and work. While overall access to foot care was higher than anticipated, routes of access differed and extent of current problems suggests the provision of effective, timely and targeted care is a pressing need.

Knee joint kinetics in response to multiple three-dimensional printed, customised foot orthoses for the treatment of medial compartment knee osteoarthritis.

The knee adduction moment is consistently used as a surrogate measure of medial compartment loading. Foot orthoses are designed to reduce knee adduction moment via lateral wedging. The 'dose' of wedging required to optimally unload the affected compartment is unknown and variable between individuals. This study explores a personalised approach via three-dimensional printed foot orthotics to assess the biomechanical response when two design variables are altered: orthotic length and lateral wedging. Foot orthoses were created for 10 individuals with symptomatic medial knee osteoarthritis and 10 controls. Computer-aided design software was used to design four full and four three-quarter-length foot orthoses per participant each with lateral posting of 0° 'neutral', 5° rearfoot, 10° rearfoot and 5° forefoot/10° rearfoot. Three-dimensional printers were used to manufacture all foot orthoses. Three-dimensional gait analyses were performed and selected knee kinetics were analysed: first peak knee adduction moment, second peak knee adduction moment, first knee flexion moment and knee adduction moment impulse. Full-length foot orthoses provided greater reductions in first peak knee adduction moment (p = 0.038), second peak knee adduction moment (p = 0.018) and knee adduction moment impulse (p = 0.022) compared to three-quarter-length foot orthoses. Dose effect of lateral wedging was found for first peak knee adduction moment (p < 0.001), second peak knee adduction moment (p < 0.001) and knee adduction moment impulse (p < 0.001) indicating greater unloading for higher wedging angles. Significant interaction effects were found for foot orthosis length and participant group in second peak knee adduction moment (p = 0.028) and knee adduction moment impulse (p = 0.036). Significant interaction effects were found between orthotic length and wedging condition for second peak knee adduction moment (p = 0.002). No significant changes in first knee flexion moment were found. Individual heterogeneous responses to foot orthosis conditions were observed for first peak knee adduction moment, second peak knee adduction moment and knee adduction moment impulse. Biomechanical response is highly variable with personalised foot orthoses. Findings indicate that the tailoring of a personalised intervention could provide an additional benefit over standard interventions and that a three-dimensional printing approach to foot orthosis manufacturing is a viable alternative to the standard methods.