A clinical practice guideline for the management of the foot and ankle in rheumatoid arthritis.

Rheumatoid arthritis causes progressive joint destruction in the long term, causing a deterioration of the foot and ankle. A clinical practice guideline has been created with the main objective of providing recommendations in the field of podiatry for the conservative management of rheumatoid arthritis. Thus, healthcare professionals involved in foot care of adults with rheumatoid arthritis will be able to follow practical recommendations. A clinical practice guideline was created including a group of experts (podiatrists, rheumatologists, nurses, an orthopaedic surgeon, a physiotherapist, an occupational therapist and patient with rheumatoid arthritis). Methodological experts using GRADE were tasked with systematically reviewing the available scientific evidence and developing the information which serves as a basis for the expert group to make recommendations. Key findings include the efficacy of chiropody in alleviating hyperkeratotic lesions and improving short-term pain and functionality. Notably, custom and standardized foot orthoses demonstrated significant benefits in reducing foot pain, enhancing physical function, and improving life quality. Therapeutic footwear was identified as crucial for pain reduction and mobility improvement, emphasizing the necessity for custom-made options tailored to individual patient needs. Surgical interventions were recommended for cases which were non-responsive to conservative treatments, aimed at preserving foot functionality and reducing pain. Moreover, self-care strategies and education were underscored as essential components for promoting patient independence and health maintenance. A series of recommendations have been created which will help professionals and patients to manage podiatric pathologies derived from rheumatoid arthritis.

Diabetic foot ulcer incidence and survival with improved diabetic foot services: an 18-year study.

AIMS: To ascertain the effects of improvements in diabetic foot services over 18 years on incidence of diabetic foot ulceration. We also compared survival time from first ulcer development with presence of neuropathy, peripheral vascular disease, age and healing. METHODS: Persons with new ulceration and those at high risk of ulcer development were referred to community podiatry from 1998. Their details were recorded, with verbal consent, on a central database. The effects of neuropathy, peripheral vascular disease, healing and age on survival were analysed by Cox proportional hazards ratios. RESULTS: The incidence of first ulcer presentation decreased from 11.1 to 6.1 per 1000 persons between 2003 to 2017 (P <0.0001). Recurrent ulceration incidence remained stable. Prevalence of chronic and new foot ulceration combined increased from 20.7 to 33.1 per 1000 persons (P <0.0001). Ten-year survival was 85% for persons presenting with first ulcer and aged < 65 years, 50% for those aged 65-74 years and 25% for those aged 75-81 years (P < 0.0001). In those with peripheral vascular disease 5-year survival was 35% (P <0.001). CONCLUSIONS: Integrated care for the diabetic foot in one National Health Service (NHS) health service area over 18 years was associated with a reduction in first presentations of diabetic foot ulceration, but failed to reduce recurrent ulceration. Cumulative prevalence of all ulcers continues to increase. Monitoring ulceration incidence can inform audit and planning of diabetic foot care services. Survival is better than reported previously in persons < 65 years and in the absence of peripheral vascular disease.

Competence areas for registered nurses and podiatrists in chronic wound care, and their role in wound care practice.

AIMS AND OBJECTIVES: To identify general competence areas for graduating registered nurses and podiatrists providing chronic wound care. BACKGROUND: The provision of care for chronic wounds involves a team of multiple professionals, and registered nurses and podiatrists play an important role. However, previous studies have found that registered nurses have limited competence in wound care. In addition, there are no standardised international competence areas for the provision of chronic wound care by registered nurses and podiatrists. DESIGN: A qualitative design was used in this study. METHODS: The data were collected using six focus-group interviews with the following professionals: (a) registered nurses; (b) authorised wound care nurses; (c) nurse educators; (d) physicians; (e) podiatrists; and (f) podiatry educators (N = 23). The data were analysed using inductive and deductive content analysis. COREQ guidelines were followed, See Appendix S1. RESULTS: The competence areas for registered nurses and podiatrists providing care for chronic wounds include knowledge, skills and performance in anatomy and physiology; aetiology, care and prevention of chronic wounds; and wound management and assessment. The competence areas also include a set of attitudes and values relating to chronic wound care and patients with chronic wounds. CONCLUSIONS: In nursing and podiatry education and in working life, teaching should focus on these areas of competence in chronic wound care. This would standardise and integrate education on wound care, especially that of chronic wounds. RELEVANCE TO CLINICAL PRACTICE: Wound care is an important part of clinical practice in nursing and podiatry. It is suggested that registered nurses and podiatrists need general competence in chronic wound care to carry out evidence-based, safe, high-quality and cost-effective care. These results could be used to define registered nurses' and podiatrists' competence areas and roles in evidence-based wound care as independent healthcare professionals.

Impact of podiatry resident experience level in hallux valgus surgery on postoperative outcomes.

BACKGROUND: Despite modern advancements in transosseous fixation and operative technique, hallux valgus (i.e., bunion) surgery is still associated with a higher than usual amount of patient dissatisfaction and is generally recognized as a complex and nuanced procedure requiring precise osseous and capsulotendon balancing. It stands to reason then that familiarity and skill level of trainee surgeons might impact surgical outcomes in this surgery. The aim of this study was to determine whether podiatry resident experience level influences midterm outcomes in hallux valgus surgery (HVS). METHODS: Consecutive adults who underwent isolated HVS via distal metatarsal osteotomy at a single US metropolitan teaching hospital from January 2004 to January 2009 were contacted and asked to complete a validated outcome measure of foot health (Manchester-Oxford Foot Questionnaire) regarding their operated foot. Resident experience level was quantified using the surgical logs for the primary resident of record at the time of each case. Associations were assessed using linear and logistic regression analyses. RESULTS: A total of 102 adult patients (n = 102 feet) agreed to participate with a mean age of 46.8 years (standard deviation 13.1, range 18-71) and average length of follow-up 6.2 y (standard deviation 1.4, range 3.6-8.6). Level of trainee experience was not associated with postoperative outcomes in either the univariate (odds ratio 0.99 [95% confidence interval, 0.98-1.01], P = 0.827) or multivariate analyses (odds ratio 1.00 [95% confidence interval, 0.97-1.02], P = 0.907). CONCLUSIONS: We conclude that podiatry resident level of experience in HVS does not contribute appreciably to postoperative clinical outcomes.

Professionalism education should reflect reality: findings from three health professions.

CONTEXT: Despite a growing and influential literature, 'professionalism' remains conceptually unclear. A recent review identified three discourses of professionalism in the literature: the individual; the interpersonal, and the societal-institutional. Although all have credibility and empirical support, there are tensions among them. OBJECTIVES: This paper considers how these discourses reflect the views of professionalism as they are expressed by students and educator-practitioners in three health care professions, and their implications for education. METHODS: Twenty focus groups were carried out with 112 participants, comprising trainee and educator paramedics, occupational therapists and podiatrists. The focus group discussions addressed participants' definitions of professionalism, the sources of their perceptions, examples of professional and unprofessional behaviour, and the point at which participants felt one became 'a professional'. RESULTS: Analysis found views of professionalism were complex, and varied within and between the professional groups. Participants' descriptions of professionalism related to the three discourses. Individual references were to beliefs or fundamental values formed early in life, and to professional identity, with professionalism as an aspect of the self. Interpersonal references indicated the definition of 'professional' behaviour is dependent on contextual factors, with the meta-skill of selecting an appropriate approach being fundamental. Societal-institutional references related to societal expectations, to organisational cultures (including management support), and to local work-group norms. These different views overlapped and combined in different ways, creating a complex picture of professionalism as something highly individual, but constrained or enabled by context. Professionalism is grown, not made. CONCLUSIONS: The conceptual complexity identified in the findings suggests that the use of 'professionalism' as a descriptor, despite its vernacular accessibility, may be problematic in educational applications in which greater precision is necessary. It may be better to assume that 'professionalism' as a discrete construct does not exist per se, and to focus instead on specific skills, including the ability to identify appropriate behaviour, and the organisational requirements necessary to support those skills.

The development of recommendations for the assessment and management of sesamoiditis by podiatrists: A Delphi and content validity study.

INTRODUCTION: Sesamoiditis is a common, and often painful, musculoskeletal pathology frequently encountered by podiatrists. However, there are currently no recommendations to guide podiatrists in the assessment and management of people with sesamoiditis. The aim of this study was to develop consensus-driven clinical recommendations on the assessment and management of people with sesamoiditis. METHODS: A four-round online Delphi survey was conducted with a panel of New Zealand and Australian podiatrists. In the first round, panellists answered open-ended questions that were used to create statements. In round two, the panellists scored the statements from 1 to 9 (1 = not at all important, 9 = absolutely essential). Consensus was defined using the RAND/University of California Los Angles Disagreement Index. Panellists were asked to reconsider statements that did not achieve consensus in round three. In the final round, content validity and acceptability of the statements for inclusion in clinical recommendations were determined using content validity ratios and the Content Validity Index (CVI). RESULTS: Eighteen panellists completed round one with 16 (89%) completing all four rounds. A total of 118 statements were generated following round one. Following rounds two and three, 78 statements were accepted by panellists as being important, with 62 statements achieving sufficient content validity for inclusion in clinical recommendations. The CVI for these 62 statements was 0.58. These recommendations provide guidance on subjective assessment (pain characteristics/symptomology, activity/sports/training history and medical history) objective assessment (establishing a diagnosis, identifying contributing biomechanical factors, footwear/orthoses, ruling out differential diagnoses) and management (temporary padding/strapping, education, footwear, foot orthoses and when to consider referral). CONCLUSION: This consensus exercise has provided a set of consensus-based recommendations for the assessment and management of people with sesamoiditis. In the current absence of research-based evidence in this area, these recommendations are intended to support clinicians. The recommendations may also serve as a basis for future clinical trials evaluating the efficacy of conservative interventions for people with sesamoiditis.

Charismatic authority in modern healthcare: the case of the 'diabetes specialist podiatrist'.

Professional specialisation is broadly considered to result from increased complexity in professional knowledge and to be linked to specialist education, formalised credentials and registration. However, the degree of formal organisation may vary across professions. In healthcare, although medical specialisation is linked to rigorous selection criteria, formal training programmes and specialist registration, some forms of specialisation in the allied health professions are much less formal. Drawing on Weber's concept of charismatic authority, the establishment of a specialist role in podiatry, the 'diabetes specialist podiatrist', in the absence of codified or credentialed authority, is explored. 'Charismatic' leaders in podiatry, having attracted a following of practitioners, were able to constitute a speciality area of practice in the absence of established career pathways and acquire a degree of legitimacy in the medical field of diabetology.

A cost-effective pressure damage prevention strategy.

This article describes the development of a pressure ulcer prevention strategy, with the aim of establishing if the implementation of best practice would impact on the incidence of pressure ulcers in a healthcare setting. The strategy was piloted in a large 78-bedded nursing home. A full audit of the patients' notes and existing care pathways was conducted in order to inform the structure of the prevention plan. It was found that there were no protocols for the use of Cavilon barrier products and that it was not part of a standard care pathway. A prevention strategy was designed based on these findings and an education package delivered to all staff. Training in the appropriate use of Aderma (TM) Dermal Pads was also provided so that they could be put in place as an early preventative measure in patients at risk of pressure damage or those showing the symptoms. The results of the study showed that by establishing a best practice care pathway, the incidence of pressure ulcers could be reduced.

Utilisation of the 2019 IWGDF diabetic foot infection guidelines to benchmark practice and improve the delivery of care in persons with diabetic foot infections.

AIMS: To utilise the 2019 International Working Group on the Diabetic Foot (IWGDF) - diabetic foot infection (DFI) guidelines as an audit tool for clinical practice in patients with diabetes attending a High-Risk Foot Service. METHODS: Data from 93 consecutive patients were collected over a 19-month period in patients attending a High-Risk Foot Service. The diagnosis and management of each patient in the sample were compared against the 2019 IWGDF DFI guidelines, grouped into four categories: Diagnosis, Microbiology, Treatment of soft tissue infection, and Surgical treatment and osteomyelitis. Deficits in performance were recorded using the recommendations as a benchmark standard. RESULTS: There were 109 DFI events. Nineteen (63%) of the recommendations were met, 7 (24%) were partially met, and four (13%) recommendations were not met. Fourteen of the sample had no documented requests for full blood counts. Tissue was obtained for culture in 32 (29%) of the sample. No percutaneous bone biopsies were performed. Only 13 (28%) patients had intraoperative bone specimens sent for culture and sensitivities, with no bone specimens sent for histopathology. Modification of antibiotic therapy following available culture results was low, occurring in 12 out of 63 possible occasions (19%). The duration of antibiotic regimens in PEDIS 2 infections and osteomyelitis was greater than that recommended. CONCLUSIONS: Utilising the IWGDF DFI guidelines to benchmark clinical practice is a useful tool to identify gaps in clinical performance or service delivery and may help to improve patient care.

Clinical guidance for podiatrists in the management of foot problems in rheumatic disorders: evaluation of an educational programme for podiatrists using a mixed methods design.

BACKGROUND: Foot and ankle problems are common in rheumatic disorders and often lead to pain and limitations in functioning, affecting quality of life. There appears to be large variability in the management of foot problems in rheumatic disorders across podiatrists. To increase uniformity and quality of podiatry care for rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthritis (SpA), and gout a clinical protocol has been developed. RESEARCH OBJECTIVES: [1] to evaluate an educational programme to train podiatrists in the use of the protocol and [2] to explore barriers and facilitators for the use of the protocol in daily practice. METHOD: This study used a mixed method design and included 32 podiatrists in the Netherlands. An educational programme was developed and provided to train the podiatrists in the use of the protocol. They thereafter received a digital questionnaire to evaluate the educational programme. Subsequently, podiatrists used the protocol for three months in their practice. Facilitators and barriers that they experienced in the use of the protocol were determined by a questionnaire. Semi-structured interviews were held to get more in-depth understanding. RESULTS: The mean satisfaction with the educational programme was 7.6 (SD 1.11), on a 11 point scale. Practical knowledge on joint palpation, programme variation and the use of practice cases were valued most. The protocol appeared to provide support in the diagnosis, treatment and evaluation of foot problems in rheumatic disorders and the treatment recommendations were clear and understandable. The main barrier for use of the protocol was time. The protocol has not yet been implemented in the electronic patient file, which makes it more time consuming. Other experienced barriers were the reimbursement for the treatment and financial compensation. CONCLUSIONS: The educational programme concerning the clinical protocol for foot problems in rheumatic disorders appears to be helpful for podiatrists. Podiatrists perceived the protocol as being supportive during patient management. Barriers for use of the protocol were identified and should be addressed prior to large scale implementation. Whether the protocol is also beneficial for patients, needs to be determined in future research.

Validity and reliability of the Australian Therapy Outcome Measures - Physiotherapy, for podiatry (AusTOMs-PT for use in podiatry).

BACKGROUND: Valid and reliable outcome measure enable measurement of health care service impact. There are limited valid and reliable outcome measures for use in podiatry practice to measure the impact of treatment. This research aimed to test the face validity of the AusTOMs for Physiotherapy (AusTOMs-PT), it's adaptability to podiatry clinical practice and the reliability of its use with podiatrists. METHODS: Stage 1 used a nominal group technique with podiatrists who worked in public and/or private settings. All podiatrists underwent self-directed training in the AusTOMs framework and measures prior to interviews or focus group discussion. Discussion was centred about transferability of the core scales of the AusTOMs-PT and an adjunct measure, AusTOMs for Occupational Therapy (AusTOMs-OT) to podiatry practice. Stage 2 used 10 case studies representative of people who had foot or ankle concerns. Podiatrists were recruited and trained in the use of the relevant AusTOMs-PT scales. Podiatrists individually scored the cases at two timepoints (1 month apart) using the six scales from the AusTOMs-PT deemed by stage 1 as relevant to podiatry. Intra and inter-rater reliability of scales were determined using intraclass correlation coefficients (ICCs). RESULTS: Thirteen podiatrists participated in individual or focus group interviews in Stage 1. Consensus was gained on six of the nine core scales adopted from the AusTOMs-PT. These were 1. Balance and Postural Control, 3. Musculoskeletal Movement Related Functions, 4. Neurological Movement Related Functions, 5. Pain, 7. Sensory Functions, 8. Skin Functions. Each core scale rated the functional domains of Impairment, Activity Limitation, Participation Restriction and Wellbeing/Distress relating to that presentation of goals of the person in the case study. There were 22 podiatrists complete training and scored two rounds of case studies using the six scales in Stage 2. There were 91%(n = 20) participants with an intra-rater ICC > 0.5 (moderate or greater). Each domain had an inter-rater reliability of > 0.9 (excellent) during the first round. CONCLUSIONS: The AusTOMs-PT for use in podiatry may be implemented to record change in impairment, function, participation and wellbeing of people receiving podiatry treatment. Podiatry specific training and mentoring, together with repeated use could be expected to improve intra-reliability.

Association between knowledge and adherence to foot self-care practices performed by diabetics.

OBJECTIVES: to verify the association between knowledge and adherence to foot self-care practices performed by patients with diabetes mellitus type 2. METHODS: cross-sectional, descriptive study carried out with 197 patients in basic health units located in the Northeast region of Brazil. For data collection, we used a semi-structured questionnaire that addressed issues inherent to knowledge and Diabetes Self-Care Activities. RESULTS: we observed that patients with moderate knowledge about self-care practices were more likely to perform foot self-examination, dry the interdigital spaces, moisturize their feet with creams and oils, observe the presence of mycosis and ingrown toenail when compared to patients with insufficient knowledge. CONCLUSIONS: the patients' level of knowledge was closely related to the self-care activities carried out, which reinforces the importance of nurses working on training those on essential health care.

Linking the effect of psoriatic arthritis-related foot involvement to the Leeds Foot Impact Scale using the International Classification for Functioning, Disability and Health: a study to assess content validity.

BACKGROUND: Previous research to describe the impact of foot involvement in psoriatic arthritis has used the Leeds Foot Impact Scale in Rheumatoid Arthritis (LFIS-RA) in the current absence of any psoriatic arthritis foot-specific tools. However, the LFIS-RA is a rheumatoid arthritis disease-specific outcome measure and its content validity for evaluating the experiences of people with psoriatic arthritis-related foot involvement is unknown. The study objective was to determine the content validity of the LFIS-RA for assessing people with psoriatic arthritis, using the International Classification of Functioning, Disability and Health (ICF) as the frame of reference. METHOD: Concepts within each item of the LFIS-RA were linked to the best-matched ICF categories using established linking rules, which enable a systematic and standardised linking process. All concepts were independently linked to the ICF by 2 investigators with different professional backgrounds, which included occupational therapy and podiatry. The list of ICF categories derived from previous research that pertained to the foot in psoriatic arthritis was then compared with the ICF categories linked to the LFIS-RA. The comparison was undertaken in order to determine the extent to which concepts important and relevant to people with psoriatic arthritis-related foot involvement were addressed. RESULTS: Thirty-five distinct ICF categories were linked to the LFIS-RA, which related to body functions (44%), activities and participation (35%), environmental factors (16%) and body structure (5%). In comparison with the ICF categories derived from concepts of the foot in psoriatic arthritis previously defined, the LFIS-RA provided coverage of key constructs including pain, functioning, daily activities, footwear restrictions and psychological impact. Other concepts of importance in psoriatic arthritis such as skin and toenail involvement, self-management and paid employment were not addressed in the LFIS-RA. CONCLUSION: Content validity of the LFIS-RA to determine the impact of foot functional impairments and disability in people with psoriatic arthritis was not supported by the results of this study. Future work should consider the development of a psoriatic arthritis foot-specific patient reported outcome measure, using the LFIS-RA as an important foundation.

Evidence-based podiatric medicine: importance of systematic reviews in clinical practice.

Due to the exponential increase in the quantity and quality of podiatric medicine-related research during the past decade, podiatric physicians are inundated with an insurmountable volume of research relevant to clinical practice. Systematic reviews can refine this literature by using explicit, rigorous, and reproducible methods to identify, critically appraise, and synthesize the best evidence from all clinical trials to answer clearly defined clinical questions. The Cochrane Collaboration is an international not-for-profit organization created to improve the user-friendliness and accessibility of medical literature mainly through preparing and maintaining systematic reviews of health-care interventions. The Cochrane Library currently contains more than 50 podiatric medicine-relevant systematic reviews summarizing and synthesizing evidence from many hundreds of randomized controlled trials evaluating interventions for foot problems. Although more than 60 countries worldwide have open online access to The Cochrane Library, in the United States, only the state of Wyoming has free access to full-text reviews. In an era demanding an evidence-based approach for every clinical intervention, high-quality systematic reviews streamline podiatric medical literature by reducing the time, cost, and training necessary to establish a solid evidence base for practice.

Public perceptions of the podiatrist and the DPM degree.

BACKGROUND: The purpose of this study was to ascertain public perception of the terms podiatry and DPM. METHODS: We distributed a survey to 847 people in ten states across the United States. It was hypothesized that most respondents would be less familiar with the DPM degree than the term podiatrist. It was also expected that people would choose MD over DPM for more complex procedures. RESULTS: The majority of respondents selected a podiatrist and a DPM as a foot specialist, almost one-half selected DPM for foot surgery, but only one-third stated they would have foot surgery done by a DPM if they had a heart problem. In addition, it was hypothesized that respondents would choose the contrived PMD over DPM simply because PMD looks more like MD; this was not shown to be true. CONCLUSIONS: Although there are gaps in the public knowledge, our study revealed a greater familiarity with podiatry and the DPM degree than originally thought.

Podiatric medicine: a current assessment.

Podiatric medicine had its own evolution in the medical field apart from allopathic and osteopathic medicine. Podiatrists are well-respected members of the health-care team and have earned recognition as physicians within their education, training, and credentialing processes. Unlike allopathic medical doctors and doctors of osteopathic medicine, whose scope of practice is based upon their education, training, and credentialing processes, podiatrists' scopes of practice are determined by state laws (and are often influenced by politics) with variances across the United States. In contrast to a lack of uniformity in the training and credentialing processes of an allopathic medical doctor, podiatrists complete a streamlined educational process that is competency-based and well-aligned from the undergraduate phase (podiatric medical school) to the postgraduate phase (residency) through the credentialing processes (licensure and certification). Podiatric medical students begin to directly engage in the specialty related to the diagnosis and treatment of the lower extremity much earlier in the educational process than an orthopedist, whose foot and ankle exposure is less extensive by comparison.

Hospital and Surgical Privileges for Doctors of Podiatric Medicine.

The Board of Directors of the American Board of Podiatric Medicine approved the following position statement regarding hospital and surgical privileges for doctors of podiatric medicine on February 27, 2019. This statement is based on federal law, Centers for Medicare and Medicaid Services Conditions of Participation and Standards of the Joint Commission, and takes into account the current education, training, and experience of podiatrists to recommend best practices for hospital credentialing and privileging.