A comparative case study of prescribing and non-prescribing physiotherapists and podiatrists.

BACKGROUND: Increasing numbers of nurses, pharmacists and allied health professionals across the world have prescribing rights for medicines: over 90,000 of the eligible United Kingdom workforce are qualified as non-doctor prescribers. In order to inform future developments, it is important to understand the benefits and impact of prescribing by allied health professionals including physiotherapists and podiatrists. AIM: to compare outcomes of physiotherapist and podiatrist Independent Prescriber (PP- IP) patients with those of physiotherapist and podiatrist non-prescribers (PP-NPs). Outcome measures included patient satisfaction, ease of access to services, quality of life and cost implications. DESIGN: a mixed method comparative case study. METHODS: Using mixed methods of data collection, outcomes were compared between 7 sites where care was provided from a PP-IP (3 podiatrist and 4 physiotherapist IPs) and 7 sites from a PP-NP (3 podiatrist and 4 physiotherapist NPs). Patients were followed up for 2 months (2015-2016). RESULTS: 489 patients were recruited: n = 243 IP sites, and n = 246 NP sites. Independent prescribing was found to be highly acceptable, and equivalent in terms of quality of life (p > 0.05) and patient satisfaction (p ≤ 0.05) compared to care provided by NPs. PP-IP care delivery was found to be more resource intensive than PP-NP, with longer consultation duration for IPs (around 6.5 mins), and a higher proportion of physiotherapy patients discussed with medical colleagues (around 9.5 min). CONCLUSION: This study provides new knowledge that PP-IPs provide high levels of care. PP-IP care delivery was found to be more resource intensive. Further research is required to explore cost effectiveness. A more focussed exploration within each profession using targeted outcome measures would enable a more robust comparison, inform future developments around the world and help ensure non-doctor prescribing is recognised as an effective way to alleviate shortfalls in the global workforce.

Differences in Achilles tendon stiffness in people with gout: a pilot study.

BACKGROUND: Gout has been associated with weaker foot/leg muscles and altered gait patterns. There is also evidence of on-going foot pain and an increased risk of tendinopathy, with the Achilles and patella tendons most frequently affected in gout. Additionally, the inflammation associated with gout may change tissue elasticity. Ultrasound imaging utilising shear wave elastography (SWE) offers a non-invasive method of quantifying changes in tendon stiffness. SWE findings have not previously been reported in individuals with gout. We sought to determine differences in Achilles tendon stiffness in people with gout compared to controls (non-gout). METHODS: A cross sectional study comparing 24 people with gout and 26 age/sex-matched controls. Clinical and demographic data were collated, and US imaging used to determine tendon thickness, presence of gouty tophi and/or aggregates and levels of angiogenesis. Ten shear wave elastography (SWE) measures were taken along the centre of a longitudinal section of the mid-portion of each Achilles tendon. Prior to data collection, intra-observer error was good (>0.69). Data were summarised using descriptive statistics and a repeated measures ANCOVA was used to compare SWE measures between the two groups for the left and right foot separately after accounting for Body Mass Index (BMI). RESULTS: A small proportion of those with gout presented with intra-tendon aggregates and/or intra-tendon tophi in one or both tendons. There was no statistically significant difference in tendon thickness between groups. Neo-vascularity was present in a third of gout participants. SWE findings demonstrated significantly reduced tendon stiffness in those with gout compared to controls: right Achilles mdiff =1.04 m/s (95% CI (0.38 to 1.7) p = 0.003 and left Achilles mdiff = 0.7 m/s (95% CI 0.09 to 1.32) p = 0.025. No relationship between the presence of tophi and SWE values were detected. CONCLUSION: Subjects with chronic gout show significantly reduced Achilles tendon stiffness compared to non-gout controls. From a clinical standpoint, our findings were similar to SWE measurements in subjects with Achilles tendinopathy and who did not have gout.

Rising to the challenge: rheumatology can lead in multi-professional education and training globally in the 21st century.

Healthcare delivery is changing, responding to needs of an ageing population with multiple long-term conditions. Safe and effective patient care in rheumatology should be delivered by a multi-professional team who understand how their roles fit individually and collectively within the team. This requires an understanding from healthcare educators and managers as to how to equip team members with the appropriate knowledge skills and behaviours, both as students and when working in clinical practice. Educational models exist that can facilitate this, and rheumatology teams in primary, community and secondary care provide an excellent opportunity to demonstrate effective team working and its impact on patient care through research and evaluation on health systems, and educational and patient outcomes.

Calciphylaxis - A case study in a patient with Maori heritage.

This case history describes a rare complaint - Calciphylaxis, seen in a New Zealand Maori patient undergoing renal dialysis. This condition causes non-healing tissue ulceration, typically with sepsis and is associated with a very high mortality rate. The need for vigilance among health professionals is highlighted, including the risk factors that may faciliate an early diagnosis; together with the value associated with a multi-disciplinary team approach to management.

"I loved it, absolutely loved it" a qualitative study exploring what student podiatrists learn volunteering as part of an interprofessional medical team at a marathon.

BACKGROUND: Final year podiatry students volunteer annually as part of the wider interprofessional medical team at both the Brighton and London Marathon race events, supervised by qualified podiatrists, allied health professionals and physicians. Volunteering has been reported to be a positive experience for all participants and a way of developing a range of professional, transferable, and where appropriate, clinical skills. We sought to explore the lived experience of 25 students who volunteered at one of these events and aimed to: i) examine the experiential learning reported by students while volunteering in a dynamic and demanding clinical field environment; ii) determine whether there were elements of learning that could be translated to the traditional teaching environment in a pre-registration podiatry course. METHODS: A qualitative design framework informed by the principles of interpretative phenomenological analysis, was adopted to explore this topic. We used IPA principles to enable analysis of four focus groups over a two-year period to generate findings. Focus group conversations were led by an external researcher, recorded, independently transcribed verbatim and anonymised prior to analysis by two different researchers. To enhance credibility, data analysis was followed by independent verification of themes, in addition to respondent validation. RESULTS: In total, five themes were identified: i) a new inter-professional working environment, ii) identification of unexpected psychosocial challenges, iii) the rigors of a non-clinical environment, iv) clinical skill development, and v) learning in an interprofessional team. Throughout the focus group conversations, a range of positive and negative experiences were reported by the students. This volunteering opportunity fills a gap in learning as perceived by students, particularly around developing clinical skills and interprofessional working. However, the sometimes-frantic nature of a Marathon race event can both facilitate and impede learning. To maximize learning opportunities, particularly in the interprofessional environment, preparing students for new or different clinical settings remains a considerable challenge.

A comparison of the readability of two patient-reported outcome measures used to evaluate foot surgery.

Measuring the outcome of surgical intervention is an integral part of modern-day healthcare provision. The increasing requirement to monitor patient-reported outcomes highlights the need for patients to be able to read and understand health outcomes questionnaires. The present study compared the readability of 2 commonly used, validated, foot surgery outcome questionnaires (the Foot Health Status Questionnaire and the Manchester-Oxford Foot Questionnaire) using the Flesch Reading Ease score and the Flesch-Kincaid grade level score. The Manchester-Oxford Foot Questionnaire had a significantly greater (p < .003) score for reading ease and a significantly lower reading grade score (p < .005) than the Foot Health Status Questionnaire. These findings suggest the Manchester-Oxford Foot Questionnaire is a more suitable instrument in terms of readability and comprehension for a greater proportion of the population undergoing hallux valgus surgery.

The podiatric surgery theatre environment in the UK; is it conducive to learning? A quantitative study using the surgical theatre educational environment measure (STEEM).

BACKGROUND: In 2015 the Health and Care Professions Council (HCPC) reported that annotation of the register for podiatric surgery would improve the way in which risks are currently managed. The academic institutions provide the teaching environment for the 'learnt' Diploma in principles of podiatric surgery however the podiatric surgery departments facilitate the production of the next generation of podiatric surgeons. This research aimed to identify the major elements that contribute to the educational environment, and find and utilise a valid assessment tool which could identify discrete areas to be targeted for improvement as well as being used for monitoring of the environment. METHODS: A quantitative study using the Surgical Theatre Educational Environment Measure (STEEM) via an online tool was utilised for podiatrists working within podiatric surgery, podiatric surgical trainees and podiatric surgeons working towards the Certificate of Completion of Podiatric Surgery Training (CCPST) with a view to assessing the educational environment within the podiatric surgical theatre in the UK. RESULTS: 16/33 responses with a response rate of 48.4% the overall STEEM mean score was 122/160. Four subscales included teaching and training, learning opportunities, atmosphere, and workload/supervision/support were measured. The overall mean score of 76.73% suggests the learning environment may be considered satisfactory; however, areas for potential improvement are identifiable. Results reveal strengths such as a non-discriminatory surgical theatre atmosphere on racial grounds. CONCLUSIONS: Perception was of a very satisfactory 'Atmosphere' within the theatre environment and a very satisfactory 'opportunity to assist' within the podiatric surgery theatre environment. The STEEM has potential to be applied further as a quality assessment tool whose results could be used to demonstrate part of the HCPC standards.

Medicines management activity with physiotherapy and podiatry: A systematic mixed studies review.

OBJECTIVE: Making best use of existing skills to increase service capacity is a global challenge. The aim was to systematically review physiotherapy and podiatrist prescribing and medicines management activity, including evidence of impact on patient care, levels of knowledge and attitudes towards extended medicines role. METHODS: A search of MEDLINE, CINAHL, and Cochrane databases, using terms to identify prescribing and medicines management across a range of roles, was conducted from January 1985 to May 2016 for physiotherapy, and January 1968 to May 2016 for podiatry. Hand searching of citations and databases from professional organisations was undertaken. Data were extracted and analysed descriptively, and quality appraised by 2 reviewers using the mixed methods appraisal tool. RESULTS: 1316 papers were identified, and 21 included in the review. No studies were identified that reported prescribing and no studies specific to podiatry met the inclusion criteria. Physiotherapists were highly involved in administering medicines, providing medicines advice, and recommending new medicines. Patient satisfaction, cost and outcomes were equivalent when comparing physiotherapist-led injection therapy to traditional care. Pharmacology knowledge was variable and unmet training needs identified. CONCLUSION: Medicines management practices were identified in physiotherapy and positive outcomes of extended scope physiotherapy. There was a lack of evidence regarding podiatric practice. Review of educational preparation for medicines management is recommended along with evaluation of medicines management practice.

Use of quantitative ultrasound scans of the calcaneus to diagnose osteoporosis in patients with rheumatoid arthritis.

BACKGROUND: Patients with rheumatoid arthritis are recognized as being at risk for osteoporosis as a result of the disease process as well as the medication used to treat it. This study was conducted to consider the use of calcaneal scanning with quantitative ultrasound-contact ultrasound bone analysis (CUBA)-to diagnose osteoporosis in patients with rheumatoid arthritis. METHODS: Forty-six patients (11 men and 35 women) with established rheumatoid arthritis underwent dual-energy x-ray absorptiometry (DEXA) of the nondominant wrist and CUBA of the nondominant heel. Sensitivity, specificity, and positive and negative predictive values were used to determine the correlation between osteoporosis as diagnosed by the CUBA heel scan compared with the DEXA wrist scan given that DEXA is widely seen as the gold standard for the diagnosis of osteoporosis. RESULTS: The CUBA heel scan revealed a sensitivity of 90% and a specificity of 44% for a diagnosis of osteoporosis compared with DEXA. The positive predictive value of the CUBA scan was 31%, and the negative predictive value was 94%. Therefore, if normal bone density is found using CUBA, there is 94% certainty this is correct. However, if osteoporosis is diagnosed using CUBA, there is only 31% certainty this is correct. In such instances a secondary scan using a different method (eg, DEXA) would be required. Future work should consider the effect of minor alterations to the equipment or scanning protocol, because this may improve diagnosis. CONCLUSIONS: The CUBA unit could be used as a primary screening device. Given the cost and accessibility issues associated with DEXA, quantitative ultrasound may have a role in screening for osteoporosis in the primary-care setting to determine the most appropriate routes of referral for patients requiring further investigations.

Clinically-evident tophi are associated with reduced muscle force in the foot and ankle in people with gout: a cross-sectional study.

BACKGROUND: The foot and ankle represent a common site for tophi in people with gout, yet it is unclear whether the presence of tophi is related to impaired muscle function. This study aimed to determine the association between foot and ankle tophi and muscle force in people with gout. METHODS: Participants with gout were stratified into two groups based on the presence of clinically-evident tophi affecting the foot or ankle on physical examination. Isometric muscle force for plantarflexion, dorsiflexion, inversion and eversion was measured using static dynamometry. Mixed-models regression was used to determine the difference in muscle force between the two groups while adjusting for age, disease duration and foot pain. This model was also used to determine the difference in muscle force between presence and absence of tophi at specific locations within the foot and ankle. In addition, Pearson's correlations were used to determine the association between total foot tophus count and muscle force. RESULTS: Fifty-seven participants were included (22 with foot or ankle tophi and 35 without foot or ankle tophi). Foot and ankle tophi were most often seen at the Achilles tendon. After adjusting for age, disease duration and foot pain, participants with tophi had significantly reduced muscle force during plantarflexion (P < 0.001), dorsiflexion (P = 0.003), inversion (P = 0.003) and eversion (P = 0.001) when compared to participants without tophi. Those with Achilles tophi had significantly reduced force during plantarflexion (P < 0.001), inversion (P = 0.008) and eversion (P = 0.001). No significant differences in muscle force were observed between the presence and absence of tophi at other foot or ankle locations. There were also no significant correlations between total foot tophus count and muscle force (all P > 0.05). CONCLUSION: In people with gout, clinically-evident foot or ankle tophi are associated with muscle force deficits during foot plantarflexion, dorsiflexion, inversion and eversion, which persist despite adjusting for age, disease duration and foot pain. Tophi at the Achilles tendon, which associate with force deficits, may contribute to reduced muscular activation and consequent disuse muscle atrophy.

Categorisation of foot complaints in systemic lupus erythematosus (SLE) from a New Zealand cohort.

BACKGROUND: Foot complaints have been shown to be common in systemic lupus erythematosus (SLE) and heterogeneous in nature. We aimed to categorize self-reported foot complaints in people with SLE and foot symptoms. METHODS: A self-administered validated questionnaire was posted to 406 people with SLE attending adult rheumatology clinics across three health boards in Auckland, New Zealand. In addition to foot pain, vascular complaints, dermatological lesions and neurological symptoms were included in the analysis. Pairwise correlations among the variables were undertaken followed by factor analysis to identify and categorise associations between reported foot complaints. RESULTS: From the questionnaires returned, 93 full datasets were analysed. Participants' were predominantly female (n = 87, 93.7%), with mean (SD) age of 50.4 (14.3) years and a mean (SD) disease duration of 13.1 (11) years. Three categories of foot complaint were determined: 'foot pain', 'skin disorders' and 'vascular insufficiency'. These three groups provided the best fit (0.91) to describe the wide range of foot complaints reported by those with SLE. Factor analysis for foot pain demonstrated a high positive loading for the inter-correlation of foot pain in past month (0.83), foot pain today (0.71), intermittent claudication (0.71), numbness (0.62), loss of balance (0.81), swelling (0.59), foot joint pain (0.77), arch pain (0.68) and tendon pain (0.77). Skin disorders demonstrated a very high positive loading for 3 factors skin rash (0.82), blistering skin rash (0.95) and foot ulceration (0.88). In vascular insufficiency a high positive loading for cold feet (0.83), chilblains (0.76) and Raynaud's phenomenon (0.70). CONCLUSIONS: This work suggests people with SLE report three independent categories of foot complaints; foot pain, skin disorders or vascular insufficiency.

Foot orthoses in the management of chronic subtalar and talo crural joint pain in rheumatoid arthritis.

BACKGROUND: This pilot study investigated whether semi-rigid and soft orthoses had an effect on pain, disability and functional limitation in participants with chronic rheumatoid hindfoot involvement. METHODS: Participants with chronic hindfoot pain were randomly assigned to 2 groups, commencing either with semi-rigid Subortholene orthoses or soft EVA orthoses. The Foot Function Index and the Ritchie Articular Index were administered pre- and post-intervention, which lasted for 3 months. Following a 2 week washout period, each group was switched over to the other type of orthoses. RESULTS: Nine female participants (mean age 52.2years (SD 9.1); mean weight 71kg (SD 12.64); mean height 160cm (SD 5.18)) with a mean RA duration of 11.7years (SD 7.83), and a mean ankle/subtalar joint pain duration of 5.7years (SD 2.62), completed the programme. Mean improvement in FFI score for both orthoses resulted in the same statistical significance (p=0.001). Statistically significant reduction in pain, disability and functional limitation was observed for both interventions, together with improvement in the Ritchie Articular Index score. CONCLUSION: Both Subortholene and EVA orthoses significantly reduced pain, disability and functional limitations in participants with chronic ankle/subtalar joint pain in rheumatoid arthritis.

Patterns of foot complaints in systemic lupus erythematosus: a cross sectional survey.

BACKGROUND: Foot complaints are common in inflammatory arthropathies such as rheumatoid arthritis and cause considerable disability. However, little is published about the nature and extent of foot complaints in systemic lupus erythematosus (SLE). We aimed to explore foot complaints among people with (SLE) and to evaluate the associations between foot pain and self-reported activities of daily living and well-being. METHODS: We developed and tested a new 40-item item self-administered questionnaire, using a five-stage development process utilising patient involvement throughout to ensure face and content validity. The self-administered instrument was posted to 406 people with SLE attending adult rheumatology clinics across three health boards in Auckland, New Zealand. The questionnaire enquired about symptoms of foot pain, extra-articular features, anatomical distribution of symptoms according to validated foot-mannequins and the impact of foot symptoms on activities of daily living and well-being. RESULTS: In total, 406 questionnaires were posted, with 131 responses (response rate 32 %). We found 89 % were women, mean (SD) age 51 (15) years, mean (SD) diagnosis 12.5 (11.1) years. Overall, 77 % of those responding to the questionnaire reported foot pain during their SLE, with 45 % reporting current foot pain. All regions of the feet were affected, with the hindfoot (32 %) and ankles (30 %) most troublesome. The most common self-reported extra-articular foot complaints were cold feet, swelling and numbness. Almost two-thirds (61 %) reported foot pain adversely affected their lives; foot pain prevented sleeping in 36 % and had a negative effect on emotions for 33 %. Only 33 % of participants had seen a podiatrist. Significant association was found between foot pain and standing longer than 15 min (p < 0.001), walking (p < 0.001), climbing stairs (p < 0.001) and going shopping (p < 0.001). Pain was the primary symptom to affect quality of life (47/100). CONCLUSION: Foot complaints in SLE are heterogeneous in nature, and may have a substantial negative impact on patient well-being. Foot complaints need to be addressed to reduce the burden of SLE and our findings support the need for wider access to specific foot care services.

Foot and ankle muscle strength in people with gout: A two-arm cross-sectional study.

BACKGROUND: Foot and ankle structures are the most commonly affected in people with gout. However, the effect of gout on foot and ankle muscle strength is not well understood. The primary aim of this study was to determine whether differences exist in foot and ankle muscle strength for plantarflexion, dorsiflexion, inversion and eversion between people with gout and age- and sex-matched controls. The secondary aim was to determine whether foot and ankle muscle strength was correlated with foot pain and disability. METHODS: Peak isokinetic concentric muscle torque was measured for ankle plantarflexion, dorsiflexion, eversion and inversion in 20 participants with gout and 20 matched controls at two testing velocities (30°/s and 120°/s) using a Biodex dynamometer. Foot pain and disability was measured using the Manchester Foot Pain and Disability Index (MFPDI). FINDINGS: Participants with gout demonstrated reduced muscle strength at both the 30°/s and 120°/s testing velocities for plantarflexion, inversion and eversion (P<0.05). People with gout also displayed a reduced plantarflexion-to-dorsiflexion strength ratio at both 30°/s and 120°/s (P<0.05). Foot pain and disability was higher in people with gout (P<0.0001) and MFPDI scores were inversely correlated with plantarflexion and inversion muscle strength at the 30°/s testing velocity, and plantarflexion, inversion and eversion muscle strength at the 120°/s testing velocity (all P<0.05). INTERPRETATION: People with gout have reduced foot and ankle muscle strength and experience greater foot pain and disability compared to controls. Foot and ankle strength reductions are strongly associated with increased foot pain and disability in people with gout.

Foot-related pain and disability and spatiotemporal parameters of gait during self-selected and fast walking speeds in people with gout: A two-arm cross sectional study.

OBJECTIVES: To examine gait parameters in people with gout during different walking speeds while adjusting for body mass index (BMI) and foot-pain, and to determine the relationship between gait parameters and foot-pain and disability. METHOD: Gait parameters were measured using the GAITRite™ walkway in 20 gout participants and 20 age- and sex-matched controls during self-selected and fast walking speeds. Foot-pain and disability was measured using the Manchester Foot Pain and Disability Index (MFPDI) which contains four domains relating to function, physical appearance, pain and work/leisure. RESULTS: At the self-selected speed, gout participants demonstrated increased step time (p=0.017), and stance time (p=0.012), and reduced velocity (p=0.031) and cadence (p=0.013). At the fast speed, gout participants demonstrated increased step time (p=0.007), swing time (p=0.005) and stance time (p=0.019) and reduced velocity (p=0.036) and cadence (p=0.009). For participants with gout, step length was correlated with total MFPDI (r=-0.62, p=0.008), function (r=-0.65, p=0.005) and physical appearance (r=-0.50, p=0.041); stride length was correlated with total MFPDI (r=-0.62, p=0.008), function (r=-0.65, p=0.005) and physical appearance (r=-0.50, p=0.041); and velocity was correlated with total MFPDI (r=-0.60, p=0.011), function (r=-0.63, p=0.007) and work/leisure (r=-0.53, p=0.030). CONCLUSION: Gait patterns exhibited by people with gout are different from controls during both self-selected and fast walking speeds, even after adjusting for BMI and foot-pain. Additionally, gait parameters were strongly correlated with patient-reported functional limitation, physical appearance and work/leisure difficulties, while pain did not significantly influence gait in people with gout.

Protective socks for people with diabetes: a systematic review and narrative analysis.

Padded socks to protect the at-risk diabetic foot have been available for a number of years. However, the evidence base to support their use is not well known. We aimed to undertake a systematic review of padded socks for people with diabetes. Additionally, a narrative analysis of knitted stitch structures, yarn and fibres used together with the proposed benefits fibre properties may add to the sock. Assessment of the methodological quality was undertaken using a quality tool to assess non-randomised trials. From the 81 articles identified only seven met the inclusion criteria. The evidence to support to use of padded socks is limited. There is a suggestion these simple-to-use interventions could be of value, particularly in terms of plantar pressure reduction. However, the range of methods used and limited methodological quality limits direct comparison between studies. The socks were generally of a sophisticated design with complex use of knit patterns and yarn content. This systematic review provides limited support for the use of padded socks in the diabetic population to protect vulnerable feet. More high quality studies are needed; including qualitative components of sock wear and sock design, prospective randomized controlled trials and analysis of the cost-effectiveness of protective socks as a non-surgical intervention.

The reliability of a smartphone goniometer application compared with a traditional goniometer for measuring first metatarsophalangeal joint dorsiflexion.

BACKGROUND: Adequate sagittal plane motion of the first metatarsalphalangeal joint (1st MTPJ) is important during normal gait and goniometric measurement is commonly used as a diagnostic and outcome assessment tool. We aimed to determine the intra and inter-rater reliability together with the concurrent validity of a universal plastic goniometer (UG) and a smartphone applicationlication (Dr G) for the measurement of dorsiflexion at the 1st MTPJ. METHODS: Measurement of joint position and passive range of motion of the 1st MTPJ dorsiflexion was compared using a UG and DrG goniometer. A double-blind repeated measures design was utilized, with intraclass correlation coefficient (ICC) used to determine levels of reliability. RESULTS: For joint position good intra-rater reliability (ICC >0.861) and good inter-rater reliability (ICC >0.823) was noted. However, the Dr G application consistently measured lower angles (mean 27.8° (SD 8.37)) than the UG (mean 32° (SD 11.7)) and these associations were significant (r = 0.399, p < 0.001). For passive range of motion, the mean total range of dorsiflexion motion (from maximum plantarflexed position to maximum dorsiflexed position) was 82.8° (SD 12.2) for the UG and 82.9° (SD 11.3) for the Dr G application. Both instruments demonstrated high levels of intra-rater reliability (ICC >0.809). Inter-rater reliability was moderate to good for the UG (ICC 0.693 (95 % CI 0.580 to 0.788)) and good for the Dr G application (ICC 0.708 (95 % CI 0.597 to 0.799)). CONCLUSIONS: Moderate to high intra and inter-rater reliability of joint position and passive 1st MTPJ motion can be achieved with traditional and smartphone-based goniometric measurement. The Dr G application may provide a slightly higher reliability, but devices should not be used inter-changeably as significant variation in measurement between devices may occur.

Forefoot plantar pressures in rheumatoid arthritis.

We sought to investigate the magnitude and duration of peak forefoot plantar pressures in rheumatoid arthritis. The spatial and temporal characteristics of forefoot plantar pressures were measured in 25 patients with a positive diagnosis of rheumatoid arthritis of 5 to 10 years' duration (mean, 8 years) and a comparison group using a platform-based pressure-measurement system. There were no significant differences between groups in the magnitude of peak plantar pressure in the forefoot region. Significant differences were, however, noted for temporal aspects of foot-pressure measurement. The duration of loading over sensors detecting peak plantar pressure was significantly longer in the rheumatoid arthritis group. In addition, the rheumatoid arthritis group demonstrated significantly greater force-time integrals. Significant increases in the temporal parameters of plantar pressure distribution, rather than those of amplitude, may be characteristic of the rheumatoid foot.

The role of outcome measures in assessing change in the at-risk rheumatoid foot.

In common with other outcome measures, those for the at-risk rheumatoid foot need to be sensitive, specific and patient focussed, although currently these combined features are not available within one measure. There is also the issue of cross-validation with other commonly used measures to be considered. Both government policy and clinical need predicate development of suitable measures for the rheumatoid foot. In the first part of this paper, general issues relating to outcome measures and some government policy are considered and in the second, outcome measures relating to the at-risk rheumatoid foot are introduced alongside a discussion on the implications for practitioners.