Outcomes and potential mechanism of a protocol to optimize foot orthoses in patients with rheumatoid arthritis.

BACKGROUND: Foot problems are highly prevalent in patients with rheumatoid arthritis. Treatment of foot problems related to rheumatoid arthritis often consists of custom made foot orthoses. One of the assumed working mechanisms of foot orthoses is redistribution of plantar pressure by creating a larger weight bearing area. Overall, the reported treatment effect of foot orthoses on foot pain in rheumatoid arthritis is small to medium. Therefore, we developed a foot orthoses optimization protocol for evaluation and adaptation of foot orthoses by using the feedback of in-shoe plantar pressure measurements. The objectives of the present study were: 1) to evaluate the 3-months outcomes of foot orthoses developed according to the protocol on pain, physical functioning and forefoot plantar pressure in patients with foot problems related to rheumatoid arthritis, and 2) to determine the relationship between change in forefoot plantar pressure and change in pain and physical functioning. METHODS: Forty-five patients with foot problems related to rheumatoid arthritis were included and received foot orthoses developed according to the protocol. Outcome measures were assessed at baseline and after three months of wearing foot orthoses in 38 patients. Change scores and effect sizes (ES) were calculated for pain, physical functioning and plantar pressure. In a subgroup of patients with combined forefoot pain and high plantar pressure, the relationship between change in plantar pressure and change in pain and physical functioning was analyzed. RESULTS: In the total group of 38 patients, statistically significant changes in pain (ES 0.69), physical functioning (ES 0.82) and forefoot plantar pressure (ES 0.35) were found. In the subgroup (n = 23) no statistically significant relationships were found between change in plantar pressure and change in pain or physical functioning. CONCLUSION: Foot orthoses developed according to a protocol for improving the plantar pressure redistribution properties lead to medium to large improvements in pain and physical functioning. The hypothesis that more pressure reduction would lead to better clinical outcomes could not be proven.

A Systematic Review of Current Surgical Interventions for Charcot Neuroarthropathy of the Midfoot.

Charcot neuroarthropathy of the foot, or Charcot foot, is a pathologic entity of the foot, associated with diabetes mellitus. Owing to the increase of diabetes mellitus in developed nations worldwide, the prevalence of Charcot foot has been increasing. The initial treatment of Charcot foot is often conservative, with methods including bracing, casting, and the use of customized orthopedic shoes. However, many cases of Charcot foot eventually require surgery, because the consequent destabilization of the foot associated with bone, joint, and nerve injury due to the pathology eventually leave patients unable to walk independently. The present systematic review analyzed the published data regarding surgical interventions for midfoot Charcot deformities and estimated the rates of common complications occurring with the surgical modalities studied. The main outcomes of interest analyzed in the present study were postoperative amputation and bony fusion. The included cohort of patients with Charcot foot was very heterogeneous in terms of the demographic and comorbid characteristics. However, even with this heterogeneity, the present study should provide useful information to surgeons in terms of the outcomes after some of the common surgical procedures for midfoot Charcot.

[Orthopedic shoe treatment: Inserts]. / Orthopädische Schuhversorgung: Einlagen.

The use of inserts and orthopedic shoe adjustment represents an essential component of the conservative therapy of degenerative diseases and deformities of the musculoskeletal system. Inserts can have supportive, bedding and corrective effects and are used in particular for complaints of the feet and ankles. The combination of diverse materials allows a high level of cushioning and supporting features and corresponding longevity to be accomplished. The production is carried out on an individual basis and if necessary computer-assisted in order to achieve an optimal fit. For severe and rigid deformities the formation of pressure ulcers can be prevented by orthopedic shoe adjustment and by the use of orthopedic tailor-made shoes.

[Foot and ankle ability measure: cross-cultural translation and validation of the Italian version of the ADL module (FAAM-I/ADL)]. / Foot and ankle ability measure: traduzione e validazione della versione Italiana del modula ADL (FAAM-I/ADL).

BACKGROUND: Valid and reliable outcome measures are fundamental for evaluating and comparing the effects of rehabilitation. Among the different tools used for the assessment of musculoskeletal disorders of the lower limb, the Foot and Ankle Ability Measure (FAAM) has been shown to have good psychometric properties. However, it has not yet been translated into Italian. The module regarding the performance of daily living activities (FAAM/ADL), in particular, can be applied also in an occupational setting. OBJECTIVE: To obtain an Italian version of the FAAM, and to validate the FAAM-I/ADL. METHODS: The cultural adaptation was performed according to international guidelines for forward/backward translation. The activities of daily living (ADL) module of the FAAM-I (FAAM-I/ADL) was validated with classical test theory methods in a convenience sample of 57 patients. Different parameters were calculated: internal consistency (Cronbach's α and item-to-total correlation); criterion validity, through Pearson's correlation (r) with the Lower Extremity Functional Scale (LEFS); test-retest reliability (ICC2,1); Standard Error of Measurement (SEM); and Minimal Detectable Change (MDC95). RESULTS: The statistical analysis showed good internal consistency (Cronbach's α=.96, item-to-total correlation ranged between .51 and .85), high criterion validity (r=.66, p<0.01) and excellent test-retest reliability (ICC2, 1=.98, CI95%=.97-.99). The SEM was 2.7 points, with a MDC95 of 7.5 points. CONCLUSIONS: FAAM-I/ADL shows good psychometric properties, together with speed and ease of administration and scoring. Its use will facilitate the comparison of Italian data with international studies, ensuring greater uniformity of assessment.

Efficacies of different external controls for excessive foot pronation: a meta-analysis.

OBJECTIVES: This meta-analysis investigated the efficacies of foot orthoses, motion control footwear and therapeutic adhesive taping in controlling foot pronation as compared with no-intervention conditions. DATA SOURCES: Electronic searches on four electronic databases were performed and the reference lists of the screened articles were also scrutinised. REVIEW METHODS: Two reviewers screened the quasi-randomised or clinical controlled trials that examined the efficacy of the selected interventions in controlling calcaneal eversion. Heterogeneity and publication bias were assessed by I(2) index and Egger's regression intercept, respectively. Trial quality was rated by the Physiotherapy Evidence Database scale. RESULTS: 29 studies were selected. The I(2) indices revealed large heterogeneity which supported the use of a random effect model of meta-analysis. The Egger's regression intercepts suggested that publication bias of the included studies was marginally present in the motion control footwear and the therapeutic adhesive taping groups (p=0.06-0.07). All three interventions were effective in reducing calcaneal eversion (p<0.001) with therapeutic adhesive taping being most effective whereas Low-dye taping was less effective than the other taping techniques, such as high-dye and stirrups taping. Custom-made foot orthoses were more effective than prefabricated orthoses. Motion control footwear with heel flare or wedge design was less effective than those with dual midsole materials. CONCLUSIONS: Foot orthoses, motion control footwear and therapeutic adhesive taping were able to control rearfoot eversion with therapeutic adhesive taping being the most effective. In the clinical practice, selection of an antipronation intervention should be based on patient characteristics, type of activity and personal preference.

Patients' expectations and actual use of custom-made orthopaedic shoes.

OBJECTIVE: To investigate the association between patients' expectations and the actual use of custom-made orthopaedic shoes. DESIGN: A prospective cohort study with internal comparison. SETTING: Twelve orthopaedic shoe companies. PATIENTS: During six months, consecutive patients who were provided with their first ever pair of orthopaedic shoes and aged 16 years or older were recruited. A total of 339 patients with different pathologies were included (response 67%). Mean (SD) age of the patients was 63 (15) years, and 129 patients (38%) were male. MAIN MEASURES: A practical and reproducible questionnaire, measuring: frequency of use of orthopaedic shoes, patients' expectations and experiences of aspects of the usability of orthopaedic shoes, and communication about patients' expectations. RESULTS: Patients' expectations were not associated with the use of orthopaedic shoes (P-values range: 0.106 to 0.607), but the difference between expectations and experiences was (P-values range: <0.001 to 0.012). The expectations of patients who frequently used their orthopaedic shoes were in concordance with their experiences, whereas the expectations of patients who did not use their orthopaedic shoes were much higher than their experiences. There was no communication of patients' expectations with the medical specialist or orthopaedic shoe technician in 34% and 25% of the patients respectively. CONCLUSIONS: In relation to the actual use of orthopaedic shoes, it is crucial that patients' expectations are not much higher than their experiences.

Clinical interpretation of computerized adaptive test outcome measures in patients with foot/ankle impairments.

STUDY DESIGN: Prospective cohort study of 10 287 patients with foot/ankle impairments receiving outpatient physical therapy. OBJECTIVES: To describe meaningful interpretations of functional status (FS) outcomes measures, estimated using a body-part-specific computerized adaptive test (CAT). BACKGROUND: Increased use of CATs to generate outcome measures in rehabilitation has stimulated questions concerning score interpretation. Identifying meaningful intra-individual change and reporting clinical interpretation of those generated outcomes are essential to advance the quality of rehabilitation practice. METHODS: We performed 4 approaches to clinically interpret outcomes data. First, we used the standard error of the estimate to construct a 90% confidence interval for each CAT estimated score. Second, we presented the percentile rank of FS scores. Third, we used 2 threshold approaches to define individual-patient-level change: statistically reliable change and clinically important change. Last, we illustrated a functional staging method. RESULTS: Precision of a single score was estimated by an FS score of +/-4. Based on score distribution, percentile ranks at 25th, 50th, and 75th percentiles corresponded to intake FS scores of 38, 47, and 57, and discharge FS scores of 52, 64, and 77, respectively. Minimal detectable change supported 7 or more FS change units out of 100 represented statistically reliable change, and ROC analyses supported 8 or more FS change units represented minimal clinically important improvement. Using a functional staging system, we established 5 hierarchical functional status levels. CONCLUSION: CAT-generated outcome measures can be interpreted to improve clinical interpretation and to assist clinicians in using patient-reported outcomes during therapy practice.

Validation of the Chinese Manchester foot pain and disability index (C-MFPDI) among patients with inflammatory arthritis.

BACKGROUND: The Manchester Foot Pain and Disability Index (MFPDI) is a patient-reported outcome tool used to measure foot pain and foot-related disability. The English version of the MFPDI has been successfully translated into other European languages, but there was no Chinese version to use in Chinese-speaking communities. The cross-sectional correlational study aimed to translate the MFPDI from English into simplified Chinese (C-MFPDI) and to test its psychometric properties among people with inflammatory arthritis in Singapore. METHODS: The MFPDI was translated from English into Chinese using a forward-backward translation framework and was administered to 100 Chinese-speaking people with inflammatory arthritis. From the original 100 participants, 30 participants re-evaluated the C-MFPDI after 2 weeks. A Visual Analogue Scale and the Taiwan Chinese Foot Function Index in simplified Chinese were used to evaluate concurrent validity with the C-MFPDI. Health-related quality of life was assessed using the Chinese version of the European Quality of Life-5 Dimension to test construct validity. RESULTS: The C-MFPDI had a high translation equivalent rate (96.3%) and content validity index (0.92), good internal consistency (Cronbach's α = 0.90) and test-retest reliability (ICC = 0.87). The concurrent validity of the C-MFPDI was demonstrated to be acceptable through its significantly moderate to strong positive correlations with the Taiwan Chinese Foot Function Index (r = 0.62-0.72, p < 0.01) and Visual Analogue Scale foot pain (r = 0.65, p < 0.01). The C-MFPDI total scores were moderately negatively associated with Chinese European Quality of Life-5 Dimension utility scores (r = - 0.40, p < 0.01). CONCLUSION: The C-MFPDI had good psychometric properties. The C-MFPDI can be used to assess disabling foot pain, impairment and disability in Chinese-speaking people with inflammatory arthritis.

Are custom-made foot orthoses of any interest on the treatment of foot pain for prolonged standing workers?

BACKGROUND: The prolonged standing position is an important factor in the onset of foot musculoskeletal disorders among workers. Safety shoes, designed to protect against the physical constraints of the work environment, do not address this issue to date. OBJECTIVES: The goal of this study is to assess the possible benefits of custom-made foot orthoses among prolonged standing workers. STUDY DESIGN: repeated measures without control group. METHODS: Thirty-four standing workers who suffer from foot pain volunteered for the study. Custom-made foot orthoses, designed by a podiatrist, were 3D-printed and distributed to each volunteer. Static balance as well as static and dynamic plantar pressure measurements were carried out with sensors inserted in the safety shoes, before and after three weeks of wearing foot orthoses daily. A questionnaire on pain and comfort was also distributed before and after treatment. RESULTS: Feelings of pain, discomfort and heavy legs were found to be significantly reduced after wearing 3D-printed orthoses (p<0.05). Additionally, in static and dynamic conditions, a significant decrease in mean peak pressure in the rearfoot area was observed along with a significant increase in mean peak pressure in the midfoot area (p<0.05). There was also a significant improvement of balance in the medial-lateral direction. CONCLUSION: Custom-made orthoses significantly increase the well-being of standing workers in our experimental testing conditions. The custom-made shape allows for a better balanced distribution of foot peak pressure thanks to its support and stimulation of the foot arches particularly through a shift of pressure from the heel to the midfoot.

If It Doesn't Work, Why Do We Still Do It? The Continuing Use of Subtalar Joint Neutral Theory in the Face of Overpowering Critical Research.

The use of subtalar joint neutral (STJN) in the assessment and treatment of foot-related musculoskeletal symptomology is common in daily practice and still widely taught. The main pioneer of this theory was Dr Merton L. Root, and it has been labeled with a variety of names: "the foot morphology theory," "the subtalar joint neutral theory," or simply "Rootian theory" or "Root model." The theory's core concepts still underpin a common approach to musculoskeletal assessment of the foot, as well as the consequent design of foot orthoses. The available literature continues to point to Dr Root's theory as the most prevalently utilized. Concurrently, the worth of this theory has been challenged due to its poor reliability and limited external validity. This Viewpoint reviews the main clinical areas of the STJN theory, and concludes with a possible explanation and concerns for its ongoing use. To support our view, we will discuss (1) historical inaccuracies, (2) challenges with reliability, and (3) concerns with validity. J Orthop Sports Phys Ther 2018;48(3):130-132. doi:10.2519/jospt.2018.0604.

Chinese cross-cultural adaptation and validation of the Foot Function Index as tool to measure patients with foot and ankle functional limitations.

PURPOSE: To perform a cross-cultural adaptation and validation of the Foot Function Index (FFI) questionnaire to develop the Chinese version. MATERIALS AND METHODS: Three hundred and six patients with foot and ankle neuromusculoskeletal diseases participated in this observational study. Construct validity, internal consistency and criterion validity were calculated for the FFI Chinese version after the translation and transcultural adaptation process. RESULTS: Internal consistency ranged from 0.996 to 0.998. Test-retest analysis ranged from 0.985 to 0.994; minimal detectable change 90: 2.270; standard error of measurement: 0.973. Load distribution of the three factors had an eigenvalue greater than 1. Chi-square value was 9738.14 (p < 0.001). Correlations with the three factors were significant between Factor 1 and the other two: r = -0.634 (Factor 2) and r = -0.191 (Factor 1). Foot Function Index (Taiwan Version), Short-Form 12 (Version 2) and EuroQol-5D were used for criterion validity. Factors 1 and 2 showed significant correlation with 15/16 and 14/16 scales and subscales, respectively. CONCLUSIONS: Foot Function Index Chinese version psychometric characteristics were good to excellent. Chinese researchers and clinicians may use this tool for foot and ankle assessment and monitoring. Implications for rehabilitation A cross-cultural adaptation of the FFI has been done from original version to Chinese. Consistent results and satisfactory psychometric properties of the Foot Function Index Chinese version have been reported. For Chinese speaking researcher and clinician FFI-Ch could be used as a tool to assess patients with foot disease.

Footwear choices for painful feet - an observational study exploring footwear and foot problems in women.

BACKGROUND: A high percentage of the population report footwear related foot pain, yet there is limited research on the effect footwear has on the development of this pain. The aim of this study was to establish whether footwear purchased by patients have an association with foot pain and what choices determined a purchase decision. METHODS: Shape and size measurements of the dominant foot and footwear (length and width) were taken from 67 female participants who routinely received podiatric treatment. Participants were also asked to complete a short questionnaire to rate the shoe characteristics, emotions whilst wearing and reasons for the purchase. RESULTS: Results highlighted a high prevalence of structural foot pathology for those over 61 who preferred slip on shoes. This group also wore shoes that were significantly narrower than their feet with width difference correlating to the presence of Hallux Abductovarus (HAV). In addition, results indicate that individual footwear advice is more important than previously thought, as it is clear that choice of footwear worn to podiatry appointments are not always worn on a daily basis. CONCLUSIONS: This study emphasises that the width of the shoe is an important part of fit, highlighting the need for patient specific footwear assessment and education for behaviour changes.

A protocol for a randomised controlled trial of prefabricated versus customised foot orthoses for people with rheumatoid arthritis: the FOCOS RA trial [Foot Orthoses - Customised v Off-the-Shelf in Rheumatoid Arthritis].

BACKGROUND: Foot pain is common in rheumatoid arthritis and appears to persist despite modern day medical management. Several clinical practice guidelines currently recommend the use of foot orthoses for the treatment of foot pain in people with rheumatoid arthritis. However, an evidence gap currently exists concerning the comparative clinical- and cost-effectiveness of prefabricated and customised foot orthoses in people with early rheumatoid arthritis. Early intervention with orthotics may offer the best opportunity for positive therapeutic outcomes. The primary aim of this study is to evaluate the comparative clinical- and cost-effectiveness of prefabricated versus customised orthoses for reducing foot pain over 12 months. METHODS/DESIGN: This is a multi-centre two-arm parallel randomised controlled trial comparing prefabricated versus customised orthoses in participants with early rheumatoid arthritis (< 2 years disease duration). A total of 160 (a minimum of 80 randomised to each arm) eligible participants will be recruited from United Kingdom National Health Service Rheumatology Outpatient Clinics. The primary outcome will be foot pain measured via the Foot Function Index pain subscale at 12 months. Secondary outcomes will include foot related impairments and disability via the Foot Impact Scale for rheumatoid arthritis, global functional status via the Stanford Health Assessment Questionnaire, foot disease activity via the Rheumatoid Arthritis Foot Disease Activity Index, and health-related quality of life at baseline, 6 and 12 months. Process outcomes will include recruitment/retention rates, data completion rates, intervention adherence rates, and participant intervention and trial participation satisfaction. Cost-utility and cost-effectiveness analyses will be undertaken. DISCUSSION: Outcome measures collected at baseline, 6 and 12 months will be used to evaluate the comparative clinical- and cost- effectiveness of customised versus prefabricated orthoses for this treatment of early rheumatoid arthritis foot conditions. This trial will help to guide orthotic prescription recommendations for the management of foot pain for people with early rheumatoid arthritis in future. TRIAL REGISTRATION: ISRCTN13654421. Registered 09 February 2016.

Custom-made foot orthoses: an analysis of prescription characteristics from an Australian commercial orthotic laboratory.

BACKGROUND: Foot orthoses are widely used in the prevention and treatment of foot disorders. The aim of this study was to describe characteristics of custom-made foot orthosis prescriptions from a Australian podiatric orthotic laboratory. METHODS: One thousand consecutive foot orthosis prescription forms were obtained from a commercial prescription foot orthosis laboratory located in Melbourne, Victoria, Australia (Footwork Podiatric Laboratory). Each item from the prescription form was documented in relation to orthosis type, cast correction, arch fill technique, cast modifications, shell material, shell modifications and cover material. Cluster analysis and discriminant function analysis were applied to identify patterns in the prescription data. RESULTS: Prescriptions were obtained from 178 clinical practices across Australia and Hong Kong, with patients ranging in age from 5 to 92 years. Three broad categories ('clusters') were observed that were indicative of increasing 'control' of rearfoot pronation. A combination of five variables (rearfoot cast correction, cover shape, orthosis type, forefoot cast correction and plantar fascial accommodation) was able to identify these clusters with an accuracy of 70%. Significant differences between clusters were observed in relation to age and sex of the patient and the geographic location of the prescribing clinician. CONCLUSION: Foot orthosis prescriptions are complex, but can be broadly classified into three categories. Selection of these prescription subtypes appears to be influenced by both patient factors (age and sex) and clinician factors (clinic location).

Ketoprofen gel as an adjunct to physical therapist management of a child with Sever disease.

BACKGROUND AND PURPOSE: Sever disease is the most common cause of heel pain in athletic children. The purpose of this case report is to describe the addition of ketoprofen gel to the physical therapy intervention of a child with Sever disease. CASE DESCRIPTION: The patient was an 8-year-old girl diagnosed with Sever disease. Physical therapy intervention consisted of 6 visits over a 3-week period with traditional interventions (including rest, discontinuation of activities that aggravate the condition, hot and cold packs, heel lifts, calf stretching, and strengthening) and the addition of ketoprofen gel to reduce local inflammation and relieve pain. OUTCOMES: The patient demonstrated improvement in all outcome measures: pain rating, the Lower Extremity Functional Scale, strength, and range of motion. DISCUSSION: The child had relief of pain and returned to activities after 18 days of intervention, which was 30 days less than reports of intervention in the literature that did not include the use of ketoprofen gel.

Effectiveness of custom-made orthopaedic shoes in the reduction of foot pain and pressure in patients with degenerative disorders of the foot.

BACKGROUND: Degenerative disorders of the foot often are painful during standing and walking. It is assumed that, because of bone deformity, callus, and deformity of the plantar pads, the plantar pressure distribution changes. Prescription of orthopaedic shoes for patients with degenerative disorders of the foot is based on the hypothesis that excessive pressure under the foot causes pain. The goal of this study was to evaluate the effectiveness of custom-made orthopaedic shoes, in terms of pressure and pain, in patients with degenerative disorders of the foot. Additionally, the relationship between plantar pressure parameters and foot pain was studied, with special emphasis on second and third metatarsal heads. METHODS: Seventy-seven consecutive patients with degenerative disorders of the foot were recruited from the outpatient clinics of seven rehabilitation centers and rehabilitation departments of university hospitals in the Netherlands. The study was prospective. The Questionnaire for Usability Evaluation for Orthopaedic Shoes was used to measure perceived foot pain. To measure plantar pressures, the Pedar in-shoe pressure measurement system (Novel GmbH, Munich) was used. The effectiveness of custom-made orthopaedic shoes, in terms of pressure and pain in patients with degenerative disorders of the foot, was analyzed by means of a paired sample t-test. To select the pressure parameter (Pmax, P(TI,) and P(av)) most closely associated with walking pain, within-subject correlation coefficients were calculated. RESULTS: Custom-made orthopaedic shoes significantly decreased perceived foot pain by at least 23%, and significantly reduced plantar pressure under all foot regions by at least 9%. A significant correlation (r = 0.521) was found between walking pain and the average pressure beneath the second and third metatarsal heads. CONCLUSIONS: Based on these results, it can be concluded that custom-made orthopaedic shoes are effective in reducing foot pain and foot pressure. The moderate (significant) relationship between average pressure and walking pain can be used as a tool for evaluating custom-made orthopaedic shoes prescribed for patients with degenerative disorders of the foot.