The emergence of telehealth in orthotic services across the United Kingdom

COVID-19 has impacted the National Health Service provision, creating urgency for departments to adapt and adopt new ways of delivering healthcare. The purpose of this service evaluation was to determine the emergence of telehealth in orthotic services across the UK in response to COVID-19. A survey exploring telehealth use was distributed online to orthotists approximately 6 months after the first peak of COVID-19 in the UK. It gathered information on telehealth prevalence, allocated appointment length and waiting times, clinician access to technology and clinicians' opinions on the efficacy of telehealth. The survey received 77 responses with over 90% of respondents reporting using telehealth. Most reported that they expected telehealth to remain part of the service, post COVID-19. Thematic analysis produced two main themes: the impact of COVID-19 and challenges still to overcome. Findings suggest that the pandemic has resulted in a backlog of patients waiting for an orthotic appointment, with services currently understaffed and lacking resources. For telehealth to be effective orthotists must have access to appropriate technology and training on how to use telehealth platforms, be provided with appropriate guidance on which patients are appropriate for telehealth consultations and given appropriate appointment times to enable safe and effective care.

The Role of Cutaneous Microcirculatory Responses in Tissue Injury, Inflammation and Repair at the Foot in Diabetes

Diabetic foot syndrome is one of the most costly complications of diabetes. Damage to the soft tissue structure is one of the primary causes of diabetic foot ulcers and most of the current literature focuses on factors such as neuropathy and excessive load. Although the role of blood supply has been reported in the context of macro-circulation, soft tissue damage and its healing in the context of skin microcirculation have not been adequately investigated. Previous research suggested that certain microcirculatory responses protect the skin and their impairment may contribute to increased risk for occlusive and ischemic injuries to the foot. The purpose of this narrative review was to explore and establish the possible link between impairment in skin perfusion and the chain of events that leads to ulceration, considering the interaction with other more established ulceration factors. This review highlights some of the key skin microcirculatory functions in response to various stimuli. The microcirculatory responses observed in the form of altered skin blood flow are divided into three categories based on the type of stimuli including occlusion, pressure and temperature. Studies on the three categories were reviewed including: the microcirculatory response to occlusive ischemia or Post-Occlusive Reactive Hyperaemia (PORH); the microcirculatory response to locally applied pressure such as Pressure-Induced Vasodilation (PIV); and the interplay between microcirculation and skin temperature and the microcirculatory responses to thermal stimuli such as reduced/increased blood flow due to cooling/heating. This review highlights how microcirculatory responses protect the skin and the plantar soft tissues and their plausible dysfunction in people with diabetes. Whilst discussing the link between impairment in skin perfusion as a result of altered microcirculatory response, the review describes the chain of events that leads to ulceration. A thorough understanding of the microcirculatory function and its impaired reactive mechanisms is provided, which allows an understanding of the interaction between functional disturbances of microcirculation and other more established factors for foot ulceration.

How has the COVID-19 pandemic affected orthotic services in the United Kingdom?

BACKGROUND

COVID-19 has had a significant impact on the National Health Service in the United Kingdom (UK).

OBJECTIVE

This study aimed to determine the impact of COVID-19 on orthotic services in the United Kingdom.

STUDY DESIGN

Cross sectional survey.

METHODS

An online survey was distributed to UK orthotists approximately 6 months after the first peak of COVID-19. Descriptive statistics of results related to appointment waiting times, disruption of services, introduction of telehealth appointments, and clinicians' opinions on the impact of COVID-19 was completed.

RESULTS

Seventy-seven orthotists completed the survey, with many reporting that their service was closed or open only to inpatients/urgent patients at some point during the pandemic. There were substantial variation in appointment waiting times, time allocated per appointment, and increases in lead times for orthotic products across services. Over 90% reported using telehealth appointments. Results were comparable with previous research showing long appointment waiting times and indicated that the pandemic has added to this issue.

CONCLUSIONS

The pandemic has had a significant impact on orthotic services with face-to-face appointments largely reserved for urgent patients and inpatients, and services going through stages of closing and reopening, alongside the introduction of telehealth to ensure less urgent patients could continue to access orthotic care. Future service evaluation studies are required to further assess how orthotic services have been affected by the pandemic and the effectiveness of recovery plans.

A low-cost field ventilator: An urgent global need

Modern ventilators are increasingly compact and able to deliver a wide range of ventilator modes and sophisticated monitoring capabilities. However, the global availability of ventilators is woefully short of demand. Data on intensive care units (ICUs), a proxy measure for hospital ventilator capacity in low and middle-income countries (LMIC's), suggest that capacity is extremely limited where it exists at all. In LMIC's, the four most common indications for mechanical ventilation (MV) in ICUs are post-surgical care, sepsis, trauma, and maternal peripartum or neonatal complications. A significant majority of these cases can be managed with intervention involving a short course of MV. Widespread and timely access to MV can thus effectively be used to help patients in these settings and improve outcomes. This paper implores this need and highlights the requirements for a low-cost ventilator or a respiratory support device.

Prevalence of musculoskeletal injury and pain of UK-based podiatrists and the impact of enforced altered working practices

Background

Occupational musculoskeletal injuries are prevalent in healthcare workers and are reported to be profession-specific. There is, however, a paucity of information around the injuries sustained from working as a podiatrist. This paper looks at the incidence of injury from working as a podiatrist, the aggravating factors to sustain these injuries and whether the changes in workload due to the COVID-19 pandemic altered the incidence.

Methods

A modified work based musculoskeletal injury questionnaire was distributed in the UK via podiatry led social media platforms. Open and Closed questions explored the demographics of the sample, perceived injury 12 months prior to the COVID-19 pandemic and then 6 months into the lockdown. Pre and post COVID-19 data were analysed for differences and thematic analysis was included to categorise reported experiences.

Results

148 podiatrists representing 3 % of HCPC registered practitioners responded to the questionnaire. Employment status altered as a result of the COVID-19 pandemic with a 13 % reduction in those working full time. Environments also changed with domiciliary and telehealth significantly increasing (p > 0.00) and non-clinical roles being extended (p > 0.002). Pain frequency and intensity significantly (p > 0.04) increased as a result of the pandemic with shoulder pain being most frequent before lockdown altering to the neck during the lockdown. Two main themes were identified that were attributed to the causes of pain including physical demands and working in awkward spaces.

Conclusions

Work-related musculoskeletal pain in podiatrists is common with the shoulder and neck being the most frequently affected. Changes in work practices due to the restrictions enforced from the COVID-19 pandemic increased the frequency and intensity of pain mostly associated with increased domiciliary and telehealth working environments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00491-7.

Defining and grouping children's therapeutic footwear and criteria for their prescription: an international expert Delphi consensus study

OBJECTIVES

This study aimed to achieve an expert consensus on how to define and group footwear interventions for children, with a further focus on the design characteristics and prescription of off-the-shelf stability footwear for children with mobility impairment.

SETTING

A group of multinational professionals, from clinicians to those involved in the footwear industry, were recruited to ensure a spectrum of opinions.

PARTICIPANTS

Thirty panellists were contacted, of which 24 consented to participate and six withdrew before round 1, a further two withdrew after round 1. Sixteen panellists completed the consensus exercise.

PRIMARY AND SECONDARY OUTCOME MEASURES

A Delphi consensus method was employed with round 1 split into three sections: (1) terms and definitions, (2) specifics of off-the-shelf stability footwear design and (3) criteria for clinical prescription of off-the-shelf stability footwear. The panel was asked to rate their level of agreement with statements and to provide further insights through open-ended questions. The opinions of the experts were analysed to assess consensus set at 75% agreement or to modify or form new statements presented through the subsequent two rounds.

RESULTS

Therapeutic footwear was the agreed term to represent children's footwear interventions, with grouping and subgrouping of therapeutic footwear being dependent on their intended clinical outcomes (accommodative, corrective or functional). Both the heel counter and topline as well as the stiffness and width of the sole were identified as potentially influencing mediolateral stability in children's gait. A consensus was achieved in the prescription criteria and outcome measures for off-the-shelf stability therapeutic footwear for cerebral palsy, mobile symptomatic pes planus, Duchenne muscular dystrophy, spina bifida and Down's syndrome.

CONCLUSIONS

Through a structured synthesis of expert opinion, this study has established a standardisation of terminology and groupings along with prescription criteria for the first time. Reported findings have implications for communication between stakeholders, evidence-based clinical intervention and standardised outcome measures to assess effectiveness.

Total Joint Replacement of Ankle, Knee, and Hip: How Do Patients Perceive Their Operative Outcomes at 10 Years?

Background:

Patient-reported outcomes (PROMs) are an integral part of national joint registers in measuring outcomes of operative procedures and improving quality of care. There is lack of literature comparing outcomes of total ankle replacement (TAR) to total knee replacement (TKR) and total hip replacement (THR). The aim of this study was to compare PROMs between TAR, TKR, and THR patient groups at 1, 5, and 10 years.

Methods:

Prospective PROMs from patients who underwent a TAR, TKR, or THR procedure between 2003 and 2010 were studied. Patients were divided into 3 groups based on their index joint replacement (hip, knee, or ankle). Patient demographics (age, gender, body mass index), patient-reported outcome scores (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], 36-Item Short Form Health Survey [SF-36]) and patient satisfaction scores (4-point Likert scale) at follow-up were compared between the 3 groups.

Results:

Data was available on 1797 THR, 2475 TKR, and 146 TAR patients. TAR patients were younger and reported fewer number of comorbidities. All 3 groups improved significantly from preoperative to 10 years for WOMAC scores (P < .001). For SF-36 scores at 10 years, the THR group (32.2% follow-up) scored the highest for 3 domains (P = .031) when compared to the TKR group (29.1% follow-up). All 3 groups had similar outcomes for 5 of 8 domains; P < .05). For patient satisfaction, the THR group reported overall 95.1% satisfaction followed by 89.8% for the TKR group and 83.9% in the TAR group (42.4% follow-up).

Conclusion:

In this cohort with diminishing numbers over the decade of time the patients were followed up we found that patients are equally happy with functional and general health outcomes from total ankle replacement vs other major lower extremity joint replacement. TAR surgery should be considered as a viable treatment option in this patient group.

Level of Evidence:

Level III, retrospective case series.

Advancements in data analysis and visualisation techniques to support multiple single-subject analyses: an assessment of movement coordination and coordination variability

Vector coding is a data analysis technique that quantifies inter-segmental coordination and coordination variability of human movement. The usual reporting of vector coding time-series data can be difficult to interpret when multiple trials are superimposed on the same figure. This study describes and presents novel data visualisations for displaying data from vector coding that supports multiple single- subject analyses. The dataset used in this study describes the lumbar-pelvis coordination in the transverse plane during a gait cycle. The data visualisation techniques presented in this study consists of the use of colour and data bars to map and profile coordination pattern and coordination variability data. The use of colour mapping provides the option to classify commonalities and differences in patterns of coordination between segment couplings and between individuals across a big dataset. Data bars display segmental dominancy data that can provide an intuitive summary on coupling angle distribution over time. The data visualisation in this study may provide further insight on how people with adolescent idiopathic scoliosis perform goal-orientated movements following an intervention, which would support clinical management strategies.

A novel concept for low-cost non-electronic detection of overloading in the foot during activities of daily living

Identifying areas in the sole of the foot which are routinely overloaded during daily living is extremely important for the management of the diabetic foot. This work showcases the feasibility of reliably detecting overloading using a low-cost non-electronic technique. This technique uses thin-wall structures that change their properties differently when they are repeatedly loaded above or below a tuneable threshold. Flexible hexagonal thin-wall structures were produced using three-dimensional printing, and their mechanical behaviour was assessed before and after repetitive loading at different magnitudes. These structures had an elastic mechanical behaviour until a critical pressure (P _crit = 252 kPa ± 17 kPa) beyond which they buckled. Assessing changes in stiffness after simulated use enabled the accurate detection of whether a sample was loaded above or below P _crit (sensitivity = 100%, specificity = 100%), with the overloaded samples becoming significantly softer. No specific P _crit value was targeted in this study. However, finite-element modelling showed that P _crit can be easily raised or lowered, through simple geometrical modifications, to become aligned with established thresholds for overloading (e.g. 200 kPa) or to assess overloading thresholds on a patient-specific basis. Although further research is needed, the results of this study indicate that clinically relevant overloading could indeed be reliably detected without the use of complex electronic in-shoe sensors.

A systematic evaluation of cutaneous microcirculation in the foot using post-occlusive reactive hyperemia

OBJECTIVES

Cutaneous microcirculatory impairments are associated with skin injury to the foot. Post-Occlusive reactive hyperemia (PORH) is one of the quick and easy methods to assess microcirculatory function. However, there are variations in the protocols currently used. Hence, this study aimed to systematically investigate the reproducibility of PORH protocols with minimal occlusion time in the foot.

METHODS

Post-Occlusive reactive hyperemia was measured using 12 different protocols (three occlusion times, two occlusion sites and with or without temperature control) in 25 healthy adults. Each of the 12 different protocols was repeated three times, and the intraclass correlation coefficient (ICC) was calculated.

RESULTS

Intraclass correlation coefficient showed that that ankle level occlusion produced moderate to excellent reproducibility for most PORH measures. In the right foot, 30- and 60-s ankle level occlusion without temperature control showed ICC of >0.40 for all parameters except the area of hyperemia (ICC = -0.36) and biological zero to peak flow percent change (ICC = -0.46). In the left foot, 30-s ankle level occlusion without temperature control showed ICC of >0.40 for all parameters except time to latency (ICC = 0.29), after hyperemia (ICC = 0.37), and max (ICC = -0.01), and area of hyperemia (ICC = -0.36). But the 60-s protocol showed ICC > 0.40 for all except time to max (ICC = 0.38). In the hallux protocols, all three 10-, 30-, and 60-s protocols without temperature control showed moderate to excellent reproducibility (ICC > 0.40). In most cases, the temporal and area under the perfusion-time curve parameters showed poor reproducibility.

CONCLUSION

Post-Occlusive reactive hyperemia can be tested efficiently with a minimal occlusion time of 10 s with hallux occlusion and 30 s with ankle occlusion in the foot. This can suggest that microcirculatory assessment is feasible in routine practice and can potentially be included for routine assessment of foot in people with diabetes.

Validation of a non-invasive imaging photoplethysmography device to assess plantar skin perfusion, a comparison with laser speckle contrast analysis

Assessing skin perfusion is an established and reliable method to study impaired lower limb blood flow. Laser Speckle Contrast Analysis (LASCA) has been identified as the current gold standard to measure skin perfusion. Imaging photoplethysmography (iPPG) is a new low-cost imaging technique to assess perfusion. However, it is unclear how results obtained from this technique compare against that of LASCA at plantar skin. Therefore, the aim of this study was to investigate the association between the skin perfusion at the plantar surface of the foot using iPPG and LASCA. Perfusion at six plantar locations (Hallux, 1st 3rd 5th metatarsal heads, midfoot, heel) was simultaneously measured using LASCA and iPPG in 20 healthy participants. Skin thickness and skin temperature were also collected at the same plantar locations. Spearman's rank tests showed significant associations with medium strength between the perfusion values measured with LASCA and iPPG for most tested sites. No improvement in the relationship between iPPG and LASCA data was observed when controlling for either skin thickness or skin temperature. Skin perfusion values obtained using iPPG were found to be significantly associated with the corresponding values obtained using the gold standard LASCA device. Additionally, the measurement of perfusion using iPPG is shown to be robust.

Ankle Foot Orthoses: Standardisation of terminology

The term Ankle Foot Orthosis (AFO) has been standardised and defined by the International Organization for Standardisation which offers general terms for external orthoses, describing terms relating to external orthoses including the abbreviation AFO. These standards relate to functional deficiencies including a description of the person to be treated with an orthosis, clinical objectives of treatment, and functional requirements of the orthosis and offers categorisation and description of external orthoses and orthotic components using the aforementioned standards. However, it is important to point out that these definitions and standardisations only apply to the term "AFO". Yet the terms used to describe the different types of AFOs have not been standardised and defined.

Thermal characteristics of rheumatoid feet in remission: Baseline data

Objectives

Studies have shown conflicting characteristic thermographic patterns of the feet in patients with active rheumatoid arthritis (RA). However, to date no studies have compared thermographic patterns of patients with RA in remission and healthy controls. Thus this study aimed to investigate whether the thermal characteristics of the feet of RA patients, in clinical and radiological remission differ to those of healthy controls.

Methods

Using convenience sampling, RA patients were recruited upon confirmed absence of synovitis by clinical examination and musculoskeletal ultrasound. Thermal images of the feet were taken. Each foot was subdivided into medial, central, lateral, forefoot and heel regions. Subsequently, temperatures in the different regions were analyzed and compared to a cohort of healthy adults.

Results

Data from 32 RA patients were compared to that of 51 healthy controls. The Independent samples T-Test demonstrated a significant difference in temperatures in all the regions of the forefoot between RA participants versus healthy subjects (Table 1). Using the One-Way ANOVA test, no significant difference was found between all the forefoot regions (p = 0.189) of RA patients. Independent sample T-test found significant differences in all heel regions between the two groups (Table 2). One-Way ANOVA demonstrated no significant differences (p = 0.983) between the different foot regions (n = 192) of RA patients.

Conclusion

These findings suggest that RA patients in clinical and radiological remission exhibit significantly different feet thermographic patterns compared to healthy controls. This data will provide the basis for future studies to assess whether thermographic patterns change with disease activity.

Analysing patterns of coordination and patterns of control using novel data visualisation techniques in vector coding

OBJECTIVE

Vector coding is a non-linear data analysis technique that quantifies inter-segmental coordination and coordination variability. The traditional approach of reporting time-series data from vector coding can be problematic when overlaying multiple trials on the same illustration. The objective of this study was to describe and present novel data visualisations for displaying the coordination pattern, segmental dominancy, range of motion on an angle-angle diagram, and coordination variability. This allows for a comparison of data across multiple participants with a focus on single subject analysis.

METHODS

Novel data visualisation techniques that involve the use of colour and data bars to map and profile coordination pattern and coordination variability data. The introduction and profiling of inter-data point range of motion quantifies range of motion of the dominant segment on an angle-angle plot and illustrates patterns of movement control. As an example, the dataset used the Istituto Ortopedico Rizzoli foot model to describe rearfoot-forefoot and shank-foot coordination during stance.

RESULTS

The use of colour mapping provides the option to inspect an entire dataset and to compare data across multiple participants, groups, and segment couplings. Combining coupling angle mapping with segmental dominancy profiling offers an intuitive and instant summary on coupling angle distribution. The novel inclusion of inter-data point range of motion profiling provides meaning to the interpretation of segmental dominancy data and demonstrates distinct patterns of movement control.

CONCLUSIONS

The use of colour mapping and profiling techniques highlighted differences in coordination pattern and coordination variability data across several participants that questions the interpretation and relevance of reporting group data. Colour mapping and profiling techniques are ideal reporting methods to compliment prospective multiple single-subject design studies and to classify commonalities and differences in patterns of coordination and patterns of control between individuals or trials. The data visualisation approaches in the current study may provide further insight on overuse injuries, exercise prescription and rehabilitation interventions.

Comparative study of the strength characteristics of a novel wood-plastic composite and commonly used synthetic casting materials

BACKGROUND

Woodcast® is a wood-plastic composite casting material that becomes pliable and self-adhesive when heated to 65 °C and returns to being weightbearing as it cools down. The present study aims to test whether this novel non-toxic casting material is strong enough for clinical use by comparing its strength against materials that are already used in weightbearing casting applications such as total contact casts.

METHODS

The strength of Woodcast® samples was compared against the strength of two commonly used synthetic casting materials (Delta-Cast®, OrthoTape). The effect of environmental factors such as cooling, prolonged heating and exposure to water was also assessed.

FINDINGS

The results of this study indicated that Woodcast® is stronger than the synthetic casting materials in compression but weaker in tension. The flexural strength of Woodcast® was 14.24 MPa (±1.25 MPa) while the respective strength of Delta-Cast® and OrthoTape was 18.96 MPa (±7.46 MPa) and 12.93 MPa (±1.93 MPa). Independent samples t-test indicated that the difference between Woodcast® and the other two materials was not statistically significant (P > .05). Woodcast® recovered 90% and 78% of its tensile or flexural strength respectively after 15 min of cooling at ambient temperature and its strength was not reduced by prolonged heating. On average, exposure to water reduced the flexural strength of Delta-Cast® by 6% and of OrthoTape by 44%. The strength of Woodcast® was not affected by exposure to water.

INTERPRETATION

The comparison between Woodcast® and commonly used synthetic casting materials indicated that Woodcast® is indeed strong enough to be safely used in weightbearing casting applications.

Does user perception affect adherence when wearing biomechanically optimised ankle foot orthosis - footwear combinations: A pilot study

STUDY DESIGN

Pilot study.

BACKGROUND

Ankle foot orthoses (AFOs) and footwear combination (FC) is a commonly prescribed medical device given to children with cerebral palsy (CP) in an attempt to improve their gait. Biomechanically optimising the AFO-FC often requires large adaptations to the sole of the user's footwear. There is currently a dearth of literature regarding the user's perception of wearing biomechanically optimised AFOs and adapted footwear and whether their perception affects their adherence to orthotic treatment.

OBJECTIVE

This study aimed to investigate perception and adherence to wearing an AFO and FC the participants were asked to wear as part of their orthotic prescription. In particular, whether the visibly modified footwear affected the user's adherence to the orthotic treatment.

METHODS

Questionnaire devised for the purpose of this study.

RESULTS

All five participants responded to the questionnaire; reporting a high number of positive responses in relation to function, including; an improvement in the way they walked, improved balance and fewer falls. Conversely, there was a high level of negative responses regarding aesthetics, with all participants reporting they did not like the cosmesis of their AFO-FCs. They were conscious that the modification to their footwear was noticeable and therefore different from their peers, yet they adhered to the treatment and in some cases increased the wearing time.

CONCLUSIONS

This pilot set of questions indicated that cosmesis is an important factor for children who wear AFOs and adapted footwear. It can be concluded that the impact of the adapted AFO-FC on the participants' function outweighed their opinion on the cosmesis of the device.

CLINICAL RELEVANCE

It is vital to understand how orthotic prescriptions affect user adherence. Orthotic prescriptions which are not utilised by the user result in a failed treatment intervention, regardless of the scientific application underpinning them.

The effect of tuning ankle foot orthoses-footwear combinations on gait kinematics of children with cerebral palsy: A case series

STUDY DESIGN

Case series.

BACKGROUND

AFOs are a commonly prescribed medical device given to children with cerebral palsy (CP) in an attempt to improve their gait. The current literature is equivocal on the effects AFOs have on the gait of children with CP. The vast majority of AFOs issued are not subject to AFO-FC tuning. There are emerging studies investigating the effects tuning AFO-FCs has on the gait of children with CP. However, the research is limited, and there is a lack of quantitative data.

OBJECTIVE

To compare the kinematics of tuned versus non-tuned gait in children with CP.

METHODS

Gait analysis assessment of five children aged between 7-11 years with a diagnosis of CP (one hemiplegic and four diplegic participants, two female, three male, with a Gross Motor Functional Classification System (GMFCS) of 2) at a Gait Analysis Laboratory.

RESULTS

In comparison to barefoot and non-tuned gait, walking with a tuned AFO-FC produced improvements in several key gait parameters. Including hip flexion and extension, posterior pelvic tilt and knee extension. Results also indicated that the type of gait pattern demonstrated by the participant affected the outcomes of tuning.

CONCLUSIONS

Tuning the AFO-FC of children with CP has the potential to improve hip function, pelvic function, knee extension in stance phase and knee flexion during swing phase and that a non-tuned AFO-FC can potentially decrease hip function, posterior pelvic tilt and increase knee extension.

CLINICAL RELEVANCE

Whilst AFO-FC tuning has been recommended for routine clinical practice, there still remains a paucity of research on the kinematic effects of using a tuned AFO-FC compared to a non-tuned. This paper provides a comparison of kinematics on children with CP, during barefoot, non-tuned and tuned AFO-FC walking with a view to inform clinical practice.

Effectiveness of therapeutic footwear for children: A systematic review

BACKGROUND

It is estimated that 2% of the global childhood population is living with some form of mobility impairment. Although footwear interventions are proposed to aid ambulation, there appears to be a paucity in the understanding of the effects of therapeutic footwear. This review aims to explore the effectiveness of footwear as an intervention for mobility impairment in children.

METHODS

A systematic search of MEDLINE, CINAHL, PubMed, SPORTdiscus and Scopus databases were performed. Studies which focused on children with some form of mobility impairment, age of 9 months to 18 years, therapeutic footwear that allowed walking, and outcome measures that had explored biomechanical or skeletal geometry or psychosocial aspects were included in this review. Modified Downs and Black quality assessment index of randomised and non-randomised studies were used to assess the methodologies of included papers.

RESULTS

Out of 5003 articles sourced, 13 met the inclusion criteria for this review. These were grouped into two titled "corrective and "functional" based on the types of footwear used for intervention. Studies within the corrective footwear group included participants aged 11 months to 5 years with moderate congenital talipes equino varus or mobile pes planus. While using skeletal geometry as an outcome, there was a limited fair quality (level II) evidence that corrective footwear has no significant effect on the development of pes planus but may assist in the reduction of deformity in congenital talipes equino varus. The functional footwear group included participants aged 3 to 17 years, predominantly with mobile pes planus or cerebral palsy. Based on biomechanical measures as an outcome, there was a limited fair quality (level III) evidence that functional footwear alters biomechanical parameters in mobile pes planus (spatiotemporal) and cerebral palsy (spatiotemporal, kinematic). Although psychosocial outcomes were considered within two studies, the analysis was limited.

CONCLUSION

Only a limited number of studies have explored the effects of therapeutic footwear and only in a narrow range of mobility impairments. Further high-quality research is required to improve the evidence base for the effectiveness of therapeutic footwear. This should include a wide range of mobility impairments and should focus both on physical and psychosocial outcomes.

Predicting the risk of future diabetic foot ulcer occurrence: a prospective cohort study of patients with diabetes in Tanzania

OBJECTIVES

The aim of this study was to identify the parameters that predict the risk of future foot ulcer occurrence in patients with diabetes.

RESEARCH DESIGN AND METHODS

1810 (male (M)/female (F): 1012/798) patients, with no foot ulcer at baseline, participated in this study. Data from a set of 28 parameters were collected at baseline. During follow-up, 123 (M/F: 68/55) patients ulcerated. Survival analyses together with logistic regression were used to identify the parameters that could predict the risk of future diabetic foot ulcer occurrence.

RESULTS

A number of parameters (HR (95% CI)) including neuropathy (2.525 (1.680 to 3.795)); history of ulceration (2.796 (1.029 to 7.598)); smoking history (1.686 (1.097 to 2.592)); presence of callus (1.474 (0.999 to 2.174)); nail ingrowth (5.653 (2.078 to 15.379)); foot swelling (3.345 (1.799 to 6.218)); dry skin (1.926 (1.273 to 2.914)); limited ankle (1.662 (1.365 to 2.022)) and metatarsophalangeal (MTP) joint (2.745 (1.853 to 4.067)) ranges of motion; and decreased (3.141 (2.102 to 4.693)), highly decreased (5.263 (1.266 to 21.878)), and absent (9.671 (5.179 to 18.059)) sensation to touch; age (1.026 (1.010 to 1.042)); vibration perception threshold (1.079 (1.060 to 1.099)); duration of diabetes (1.000 (1.000 to 1.000)); and plantar pressure at the first metatarsal head (1.003 (1.001 to 1.005)), temperature sensation (1.019 (1.004 to 1.035)) and temperature tolerance (1.523 (1.337 to 1.734)) thresholds to hot stimuli and blood sugar level (1.027 (1.006 to 1.048)) were all significantly associated with increased risk of ulceration. However, plantar pressure underneath the fifth toe (0.990 (0.983 to 0.998)) and temperature sensation (0.755 (0.688 to 0.829)) and temperature tolerance (0.668 (0.592 to 0.0754)) thresholds to cold stimuli showed to significantly decrease the risk of future ulcer occurrence. Multivariate survival model indicated that nail ingrowth (4.42 (1.38 to 14.07)); vibration perception threshold (1.07 (1.04 to 1.09)); dry skin status (4.48 (1.80 to 11.14)); and temperature tolerance threshold to warm stimuli (1.001 (1.000 to 1.002)) were significant predictors of foot ulceration risk in the final model. The mean time to ulceration was significantly (p<0.05) shorter for patients with: dry skin (χ²=11.015), nail ingrowth (χ²=14.688), neuropathy (χ²=21.284), or foot swelling (χ²=16.428).

CONCLUSION

Nail ingrowth and dry skin were found to be strong indicators of vulnerability of patients to diabetic foot ulceration. Results highlight that assessments of neuropathy in relation to both small and larger fiber impairment need to be considered for predicting the risk of diabetic foot ulceration.

A Synoptic Overview of Neurovascular Interactions in the Foot

Diabetes is a worldwide public health concern as it is associated with various complications. One of the major complications of diabetes is diabetic foot syndrome that results in catastrophic events such as ulceration and amputation. Therefore, the main four strategies of diabetic foot care involve risk prediction, prevention, and early diagnosis and prompt intervention. The drivers of ulceration are multifactorial, and importantly, include microcirculatory changes in the diabetic skin. Cutaneous microcirculation on the foot is greatly influenced by the small fibers which mediate thermal sensation and pain perception in addition to sympathetic activities such as thermoregulation and vasodilation. The interdependence between the neurovascular elements means with the loss of small fiber functions, the corresponding microcirculatory responses may be compromised. Thus, it can be hypothesized that the impairment of the microcirculation may follow the order of the corresponding small fiber nerve dysfunction or vice versa. In this review, select neurovascular investigations that inform the cutaneous microcirculatory and small fiber nerve function in response to pain, cold, and heat and pressure stimuli are reviewed and discussed in this order of sensory loss: the loss of pain, cold, warmth, touch and deep pressure sensation. We also discuss the neurological and vascular characteristics of each of these neurovascular responses. This review highlights the influence of small fibers on cutaneous microcirculation and the need for prospective studies that can determine the course of microcirculatory impairment over time. This, in turn, may help clarify the exact role of microcirculatory changes in the pathway of ulceration. The insights from this review can be pertinent to understand key microcirculatory disturbances and given that the microcirculatory impairment develops at an early stage, relevant interventions can be implemented to possibly reverse or regress the course of the disease. Therefore, knowledge of the neurovascular interactions aids to map the disease progression for early diagnosis and prevention of adverse complications.

Surface electromyography of the foot: A protocol for sensor placement

BACKGROUND

The use of surface EMG (sEMG) to record muscle activity is common place yet due to restrictions in technology studies on the intrinsic foot muscles have been limited or only fine wire instruments have been used.

AIM

This paper looks at the potential reliability of a sEMG protocol for assessing the intrinsic foot muscles.

METHODS

Six intrinsic muscles were defined using ultrasound and muscle function testing. A protocol for sensor placement was created with repeatability and reliability testing of the protocol conducted by three separate testers on three subjects over two different time frames. Inter tester and Inter session repeatability and reliability was measured with ICC and percentage standard error of measurement.

RESULTS

Although there was good correlation between Extensor Digitorum Brevis, Dorsal Interossei, Abductor Digiti Minimi and Flexor Digitorum Brevis there was increased variability and poor correlation for Flexor hallucis Brevis and Abductor Hallucis. The percentage standard error of measurement did not support the high ICC values indicating a lower precision of measurement.

SIGNIFICANCE

Variability between testers and sessions shows an inconsistent reliability of sEMG and further work is required with protocols focussing on grouping muscles to improve the understanding of the intrinsic foot muscles.

A comparison of thermographic characteristics of the hands and wrists of rheumatoid arthritis patients and healthy controls

Thermal imaging has been applied to detect possible temperature variations in various rheumatic disorders. This study sought to determine whether rheumatoid arthritis (RA) patients without active synovitis in their hands exhibit different baseline thermographic patterns of the fingers and palms when compared to healthy individuals. Data from 31 RA patients were compared to that of 51 healthy controls. The RA patients were recruited upon confirmed absence of synovitis by clinical examination and musculoskeletal ultrasound. Participants underwent medical infrared imaging of the regions of interest (ROIs). Significant differences were found between the mean temperatures of the palm regions (29.37 °C (SD2.2); n = 306) and fingers (27.16 °C (SD3.2); n = 510) of the healthy participants when compared to the palm regions (31.4(SD1.84)°C; n = 186) and fingers (30.22 °C (SD2.4); n = 299) of their RA counterparts (p = 0.001), with the latter group exhibiting higher temperatures in all ROIs. Logistic regression models confirm that both palm and finger temperature increase significantly in RA without active inflammation. These innovative findings provide evidence that baseline thermal data in RA differs significantly from healthy individuals. Thermal imaging may have the potential to become an adjunct assessment method of disease activity in patients with RA.

Cross-sectional survey of orthotic service provision in the UK: does where you live affect the service you receive?

OBJECTIVE

To investigate the quantity and quality of orthotic service provision within the UK.

DESIGN

Cross-sectional survey obtained through freedom of information request in 2017.

SETTING

National Health Service (NHS) Trusts/Health Boards (HBs) across the UK.

MAIN OUTCOME MEASURES

Descriptive statistics of survey results, including information related to finance, volume of appointments, patients and orthotic products, waiting times, staffing, complaints, outcome measures and key performance indicators.

RESULTS

Responses were received from 61% (119/196) of contacted Trusts/HBs; 86% response rate from Scotland (12/14) and Wales (6/7), 60% (3/5) from Northern Ireland and 58% (98/170) from England. An inhouse service was provided by 32% (35/110) of responses and 68% (74/110) were funded by a block contract. Long waiting times for appointments and lead times for footwear/orthoses, and large variations in patient entitlements for orthotic products across Trusts/HBs were evident. Variations in the length of appointment times were also evident between regions of the UK and between contracted and inhouse services, with all appointment times relatively short. There was evidence of improvements in service provision; ability for direct general practitioner referral and orthotic services included within multidisciplinary clinics. However, this was not found in all Trusts/HBs.

CONCLUSIONS

The aim to provide a complete UK picture of orthotic service provision was hindered by the low response rate and limited information provided in some responses, with greater ability of Trusts/HBs to answer questions related to quantity of service than those that reflect quality. However, results highlight the large discrepancies in service provision between Trusts/HBs, the gaps in data capture and the need for the UK NHS to establish appropriate processes to record the quantity and quality of orthotic service provision. In addition to standardising appointment times across the NHS, guidelines on product entitlements for patients and their lead times should be prescribed to promote equity.