Minimal Important Difference (MID) of two commonly used outcome measures for foot problems

Foot health of Aboriginal and Torres Strait Islander Peoples in regional and rural NSW, Australia

BACKGROUND

Foot health of Aboriginal and Torres Strait Islander Australians' has not been established. Additionally, studies have shown that there is a lack of engagement of this population with general preventive foot care services. The aim of this study was to establish foot health in Aboriginal and Torres Strait Islander people attending two recently developed, culturally safe podiatry services in rural and regional New South Wales (NSW), Australia. Secondarily the relationship between self-perceived foot health and some medical and demographic characteristics was investigated.

METHODS

This descriptive cross-sectional study included participants attending the culturally safe foot health care services managed by the University of Newcastle on the Central Coast or in Wellington, both located in NSW, Australia. At the consultation, participants completed the Foot Health Status Questionnaire (FHSQ) with the assistance of an Aboriginal health care worker, underwent basic vascular and neurological screening, and podiatric treatment.

RESULTS

A total of 111 Aboriginal and Torres Strait Islander Australians (48 from the Central Coast, and 63 from Wellington) were included. FHSQ scores for pain (75.7 ± 26.8), function (80.2 ± 25.2), footwear (53.9 ± 33.4), and general foot health (62.0 ± 30.9) were generally good, but below the optimal score of 100. The presence of diabetes (n = 39 of 111 participants or 35.1%) was associated with lower levels of self-perceived foot function (r = - 0.20, n = 107, p = 0.04).

CONCLUSION

We found that community-based foot health care services that are culturally safe are utilised by Aboriginal and Torres Strait Islander Peoples not currently at high risk of foot complications. This supports the use of culturally safe foot care services to improve engagement with preventative foot care. Future research should continue to be driven by Aboriginal and Torres Strait Islander Peoples and investigate ways to implement additional screening measures and undertake prospective evaluation of the impact of such services on health related outcomes in these communities.

Foot health among the Roma population of southern Spain according to the foot health status questionnaire

BACKGROUND

Foot health of the Roma population is a challenge for the health professionals where this minority is significant, as is the case in Spain. At present, little is known about foot health of the Roma population and their knowledge would promote the training of these professionals at the community level. Foot pain is common and a reason for consulting podiatry services. The purpose of this study was to determine foot health among the Roma population according to the Foot Health Status Questionnaire.

METHOD

An observational, cross-sectional and quantitative study conducted at the Roma population living in Spain in 2018. Self-reported data and the Foot Health Status Questionnaire were recorded. Examining the general health and foot health (foot pain, foot function, footwear and general health) and general (general health, social capacity, physical activity and vigour). This questionnaire is recommended as a valid and reliable patient-reported outcome. The obtained scores were compared.

RESULTS

A sample made up of 624 men and women from the Roma population took part in this study. 45% were Roma men and 55% Roma women. In the first section of the FHSQ, a lower score of values was recorded in the footwear domain (62.5) and in the general foot health domain (60). Gypsy women obtained lower scores in all the domains. In the second section, lower scores were obtained in the vigour (56) domain and in the general health (60) domain. A large effect size (r-Rosenthal) was found by gender in the footwear domain (0.334) and in the vigour domain (0.195). Roma women showed higher values in cardiac disorders, serious illnesses, doctor visits and foot problems. 67.8% reported that they had never been assisted by a podiatrist.

CONCLUSIONS

The studied Roma population has foot health problems, and these are more pronounced among women. They show lower values in the footwear and vigour domains. More professional training is required for health workers in this field to avoid cultural diversity stereotypes.

Effects of midfoot joint mobilization on ankle-foot morphology and function following acute ankle sprain. A crossover clinical trial

BACKGROUND

Midfoot joint impairment is likely following lateral ankle sprain (LAS) that may benefit from mobilization.

OBJECTIVE

To investigate the effects of midfoot joint mobilizations and a one-week home exercise program (HEP) compared to a sham intervention and HEP on pain, patient-reported outcomes (PROs), ankle-foot joint mobility, and neuromotor function in young adults with recent LAS.

METHODS

All participants were instructed in a stretching, strengthening, and balance HEP and were randomized a priori to receive midfoot joint mobilizations (forefoot supination, cuboid glide and plantar 1st tarsometatarsal) or a sham laying-of-hands. Changes in pain, physical, psychological, and functional PROs, foot morphology, joint mobility, pain-to-palpation, neuromotor function, and dynamic balance were assessed pre-to-post treatment and one-week following. Participants crossed-over following a one-week washout to receive the alternate treatment and were assessed pre-to-post treatment and one-week following. ANOVAs, t-tests, proportions, and 95% confidence intervals (CI) were calculated to assess changes in outcomes. Cohen's d and 95% CI compared treatment effects at each time-point.

RESULTS

Midfoot joint mobilization had greater effects (p < .05) in reducing pain 1-week post (d = 0.8), and increasing Single Assessment Numeric Evaluation (immediate: d = 0.6) and Global Rating of Change (immediate: d = 0.6) compared to a sham treatment and HEP.

CONCLUSION

Midfoot joint mobilizations and HEP yielded greater pain reduction and perceived improvement compared to sham and is recommended in a comprehensive rehabilitation program following LAS.

Higher body mass index is associated with lower foot health in patients with rheumatoid arthritis: baseline results of the Amsterdam-Foot cohort

Objective: Obesity is highly prevalent in patients with rheumatoid arthritis (RA), with likely impact on weight-bearing foot joints. We explored the associations between body mass index (BMI) and measures of foot health in patients with RA and foot complaints.Method: We examined patients with RA presenting for their first custom-made therapeutic footwear or foot orthoses. Domains of foot health comprised: foot pain, foot-related activity limitations, forefoot plantar pressure, foot synovitis, and foot deformity. In regression analyses, BMI was the independent variable and foot health domains were the dependent variables.Results: The cohort at baseline comprised 230 patients [mean ± sd age 58 ± 13 years, 80% female, mean ± sd disease duration 10 ± 9 years, and median (interquartile range) BMI 26.7 (23.5-30.1) kg/m²]. Small to modest statistically significant associations were found in the majority of the measures studied between a higher BMI and more foot pain, more foot-related activity limitations, higher in-shoe measured forefoot plantar pressure, and the presence of foot synovitis. No relationships were found between BMI and barefoot measured forefoot plantar pressure or foot deformity.Conclusion: BMI is negatively associated with foot health in patients with RA. Although the clinical relevance of our findings for an individual patient is not immediately obvious, future research should consider BMI as a potential therapeutic target to improve foot health.

[Comparison between extracorporeal shockwave therapy and radial pressure wave therapy in plantar fasciitis]

OBJECTIVE

Plantar fasciitis is a common cause of heel pain. The aetiology of this condition remains unclear. Patients typically have pain upon palpation of the medial plantar calcaneal region. Extracorporeal shockwave therapy has shown favourable outcomes in various studies. The aim of this study was to compare the effect of focused extracorporeal shockwave therapy with radial pressure wave therapy.

PATIENTS AND METHODS

Seventy-nine non-randomised patients diagnosed with plantar fasciitis were included between January 2017 and June 2018. Patients from the Arnau de Vilanova Hospital in Valencia were treated with focused extracorporeal shockwave therapy, and patients from Llíria Hospital with radial pressure wave therapy. Measured outcome variables were: visual analog scale; ultrasonographic measurement of plantar fascia thickness; self-reported foot-specific pain and disability using the Foot Function Index; self-reported health-related quality of life using the Euroqol-5D; self-reported pain and limitations of activity using the Roles & Maudsley Scale.

RESULTS

At inclusion, the 2groups showed no significant differences in demographic or clinical characteristics. Three months after treatment completion, both groups showed improvement in all outcome variables, without statistically significant differences between the 2groups. No adverse effects or complications were observed.

CONCLUSIONS

Both extracorporeal shockwave therapy and radial pressure wave therapy are effective treatments for plantar fasciitis.

Corticosteroid injection plus exercise versus exercise, beyond advice and a heel cup for patients with plantar fasciopathy: protocol for a randomised clinical superiority trial (the FIX-Heel trial)

Background

Plantar fasciopathy has a lifetime prevalence of 10%. Patients experience sharp pain under the heel, often for several months or years. Multiple treatments are available, but no single treatment appears superior to the others. A corticosteroid injection offers short-term pain relief but is no better than placebo in the longer term (> 8 weeks). Heavy-slow resistance training has shown potentially positive effects on long-term outcomes (> 3 months), and combining exercises with an injection may prove to be superior to exercises alone. However, the effect of heavy-slow resistance training compared with a simpler approach of patient advice (e.g., load management) and insoles is currently unknown. This trial compares the efficacy of patient advice with patient advice plus heavy-slow resistance training and with patient advice plus heavy-slow resistance training plus a corticosteroid injection in improving the Foot Health Status Questionnaire pain score after 12 weeks in patients with plantar fasciopathy.

Methods

In this randomised superiority trial, we will recruit 180 patients with ultrasound-confirmed plantar fasciopathy and randomly allocate them to one of three groups: (1) patient advice and an insole (n = 60); (2) patient advice, an insole, and self-dosed heavy-slow resistance training consisting of heel raises (n = 60); or (3) patient advice, an insole, heavy-slow resistance training, and an ultrasound-guided corticosteroid injection (n = 60). All participants will be followed for 1 year, with the 12-week follow-up considered the primary endpoint. The primary outcome is the Foot Health Status questionnaire pain domain score. Secondary outcomes include the remaining three domains of the Foot Health Status Questionnaire, a 7-point Global Rating of Change, the Pain Self-Efficacy Questionnaire, physical activity level, health-related quality of life measured by the EQ-5D-5L, and Patient Acceptable Symptom State, which is the point at which participants feel no further need for treatment. Additionally, a health economic evaluation of the treatments will be carried out.

Discussion

This trial will test if adding heavy-slow resistance training to fundamental patient advice and an insole improves outcomes and if a corticosteroid injection adds even further to that effect in patients with plantar fasciopathy.

Trial registration

ClinicalTrials.gov, NCT03804008. Prospectively registered on January 15, 2019.

Effects of Strengthening and Stretching Exercises on the Temporospatial Gait Parameters in Patients With Plantar Fasciitis: A Randomized Controlled Trial

Objective

To investigate the effects of physical therapy interventions using strengthening and stretching exercise programs on pain and temporospatial gait parameters in patients with plantar fasciitis (PF).

Methods

Eighty-four patients with PF participated in the study and were randomly assigned to the strengthening or stretching exercise groups. All patients received 8 physical therapy interventions two times per week in the first 4 weeks and performed daily strengthening or stretching exercises three times per day. After 4 weeks, they continued the assigned exercise programs every day for 8 weeks. Pain visual analogue scale (VAS) scores at the worst and in the morning and temporospatial gait parameters were evaluated at the baseline, intermediate of the intervention, end of the intervention, and the first and second month follow-up.

Results

There were significant effects of the time on the worst pain, morning pain, cadence, stride time, stride length, total double support, and gait speed, but there was no effect on step width. In addition, the main effect of the group and the interaction effects of the time and the group were not found in any parameters. For intra-group comparisons, there were significant differences in worst pain, morning pain, cadence, and stride time among the assessment times in both groups. For inter-group comparisons, there were no significant differences in all parameters.

Conclusion

Both strengthening and stretching exercise programs significantly reduced pain and improved gait in patients with PF.

Platelet-rich plasma for sports-related muscle, tendon and ligament injuries: an umbrella review

BACKGROUND

Platelet-rich plasma (PRP) has been used in different non-transfusion indications due to its role in tissue regeneration and healing. The aim of this overview of systematic reviews (umbrella review) is to provide a summary of the existing research syntheses related to PRP use for sports-related muscle, tendon and ligament injuries.

MATERIALS AND METHODS

Literature searches were performed in MEDLINE, Embase, and Cochrane Library to identify systematic reviews focusing on PRP use for sports-related muscle, tendon and ligament injuries. The methodological quality of included studies was assessed using the checklist for systematic reviews and research syntheses developed by the Joanna Briggs Institute and the GRADE assessment.

RESULTS

Twenty-two studies met the inclusion criteria. Five studies evaluated PRP use for acute muscle injury, and 17 evaluated PRP use for tendon and ligament injury. Studies were heterogeneous in terms of the dose and number of PRP injections, and the control groups. Three of the 5 reviews evaluating acute muscle injury concluded that PRP had no effect on the outcomes considered. One review shows superior efficacy of rehabilitation exercise compared to PRP. One review shows that PRP may result in an earlier return to sport for acute grade I-II injury. Eight out of the 17 reviews evaluating PRP for tendon and ligament injuries show a statistically significant (p<0.05) difference in pain and/or function outcome measures favouring PRP compared to controls, although most of the observed differences were small. Adverse events data and quality of life outcomes were rarely analysed or reported in the included studies and were considered clinically insignificant.

DISCUSSION

In most of the included reviews, the available evidence was judged to be of low/very low quality due to risk of bias, inconsistency and imprecision, thus making the level of certainty of these findings low and not adequate to support the general use of PRP in this setting.

Concurrent Validity of the Foot Health Status Questionnaire and Study Short Form 36 for Measuring the Health-Related Quality of Life in Patients with Foot Problems

Background and Objectives: Foot problems may be considered to be a prevalent condition and impact the health-related quality of life (QoL). Considering these Spanish-validated tools, the Foot Health Status questionnaire (FHSQ) may provide a health-related QoL measurement for specific foot conditions and general status. To date, the domains of the FHSQ and Medical Outcomes Study Short Form 36 (SF-36) have not been correlated. Therefore, the main aim of this study was to correlate the domains of the FHSQ and SF-36 in patients with foot problems. Materials and Methods: A cross-sectional descriptive study was carried out. A sample of 101 patients with foot problems was recruited. A single researcher collected descriptive data, and outcome measurements (FHSQ and SF-36) were self-reported. Results: Spearman's correlation coefficients (r_s) were calculated and categorized as weak (r_s = 0.00-0.40), moderate (r_s = 0.41-0.69), or strong (r_s = 0.70-1.00). In all analyses, statistical significance was considered with a p-value < 0.01 with a 99% confidence interval. Statistically significant differences (p < 0.01) were found between all domains of FHSQ and SF-36, except for the mental health domain of the SF-36 with foot pain, foot function, and general foot health of the FHSQ, as well as between the vitality domain of the SF-36 and the general foot health domain of the FHSQ (p > 0.01). Statistically significant correlations varied from week to strong (r_s = 0.25-0.97). The strongest correlations (p < 0.001) were found for physical activity and physical function (r_s = 0.94), vigor and vitality (r_s = 0.89), social capacity and social function (r_s = 0.97), and general health domains of the SF-36 and FHSQ. Conclusions: The FHSQ and SF-36 showed an adequate concurrent validity, especially for the physical activity or function, vigor or vitality, social capacity or function, and general health domains. Nevertheless, the mental health domain of the SF-36 should be considered with caution.

The efficacy and safety of continuous versus single-injection popliteal sciatic nerve block in outpatient foot and ankle surgery: a systematic review and meta-analysis

Background

Continuous popliteal sciatic nerve block (CPSNB) has been performed in outpatient foot and ankle surgery as a regional anesthesia method to relieve postoperative pain. Its efficacy as well as safety is yet to be established. There are two purposes of this study: (1) to validate the efficacy of CPSNB with regards to better pain relief and reduced analgesics consumption; (2) to assess the safety of CPSNB.

Methods

We performed a comprehensive literature review on Web of Science, the Cochrane Library, PubMed and Embase and only included randomized controlled trials (RCTs). Five RCTs that compared the efficacy and safety of CPSNB with the single-injection popliteal sciatic nerve block group were included. The primary outcome parameters were visual analog scale (VAS) scores at postoperative 24, 48 and 72 h. The secondary outcome parameters were amount of oral analgesics consumed, overall patient satisfaction and need of admission after surgery. A sensitivity analysis was performed to explore the consistency of the results.

Results

In comparison with the single-injection group, CPSNB was associated with a lower VAS score at postoperative 24 and 48 h (p < 0.05). There were no neuropathic symptoms or infection events after the nerve block. However, there were several minor complications associated with the pump and catheter system, with drug leakage being the most common complication (N = 26 of 187, 13.9%).

Conclusion

CPSNB is an effective method in pain management for outpatient foot and ankle surgery. Both methods appear to be safe as none of the patients experienced neuropathic symptoms or infection. Further studies with larger sample size are needed to compare the risk of major complications between the two methods.

Level of evidence

I; meta-analysis.

Corticosteroid injection for plantar heel pain: a systematic review and meta-analysis

Background

Corticosteroid injection is frequently used for plantar heel pain (plantar fasciitis), although there is limited high-quality evidence to support this treatment. Therefore, this study reviewed randomised trials to estimate the effectiveness of corticosteroid injection for plantar heel pain.

Methods

A systematic review and meta-analysis of randomised trials that compared corticosteroid injection to any comparator. Primary outcomes were pain and function, categorised as short (0 to 6 weeks), medium (7 to 12 weeks) or longer term (13 to 52 weeks).

Results

A total of 47 trials (2989 participants) were included. For reducing pain in the short term, corticosteroid injection was more effective than autologous blood injection (SMD -0.56; 95% CI, − 0.86 to − 0.26) and foot orthoses (SMD -0.91; 95% CI, − 1.69 to − 0.13). There were no significant findings in the medium term. In the longer term, corticosteroid injection was less effective than dry needling (SMD 1.45; 95% CI, 0.70 to 2.19) and platelet-rich plasma injection (SMD 0.61; 95% CI, 0.16 to 1.06). Notably, corticosteroid injection was found to have similar effectiveness to placebo injection for reducing pain in the short (SMD -0.98; 95% CI, − 2.06, 0.11) and medium terms (SMD -0.86; 95% CI, − 1.90 to 0.19). For improving function, corticosteroid injection was more effective than physical therapy in the short term (SMD -0.69; 95% CI, − 1.31 to − 0.07). When trials considered to have high risk of bias were excluded, there were no significant findings.

Conclusions

Based on the findings of this review, corticosteroid injection is more effective than some comparators for the reduction of pain and the improvement of function in people with plantar heel pain. However, corticosteroid injection is not more effective than placebo injection for reducing pain or improving function. Further trials that are of low risk of bias will strengthen this evidence.

Registration

PROSPERO registration number CRD42016053216.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2749-z) contains supplementary material, which is available to authorized users.

Efficacy and safety of electroacupuncture plus warm needling therapy for heel pain: study protocol for a randomized controlled trial

BACKGROUND

Heel pain is a common foot disorder that causes pain and functional limitations. The prevalence of disabling foot pain will increase as the population ages. Previous studies have reported the positive therapeutic effects of electroacupuncture, warm needling, or the combination of both for heel pain but with limitations in the study methodologies. The current study is a rigorously designed randomized controlled trial that aims to evaluate the clinical efficacy and safety of electroacupuncture plus warm needling therapy in patients with heel pain.

METHODS/DESIGN

The study protocol describes a prospective, open-label, parallel-group, randomized controlled trial to be conducted in Hong Kong. Eighty patients aged 50-80 years who have reported heel pain and first-step pain equal to or exceeding 50 mm on the 100-mm visual analog scale (VAS) will be recruited. They will be randomly assigned (1:1 ratio) to the electroacupuncture plus warm needling therapy (i.e., treatment) group or the waitlist (i.e., control) group. The treatment group will undergo six treatment sessions in 4 weeks. The control group will receive no treatment during the study period. The primary outcome measure is a mean change in the first-step pain VAS score from the baseline to week 4. Secondary outcome measures include a mean change in first-step pain VAS score from the baseline to week 2, a mean change in Foot Function Index (FFI) subscale scores and the total score from the baseline to week 2 and week 4, and patients' self-reported level of improvement at week 4. Additional week 8 follow-up assessments with first-step pain VAS and FFI measurements will be arranged for the treatment group. Any adverse events will be recorded throughout the study to evaluate safety. An intention-to-treat approach will be used to analyze the study results.

DISCUSSION

This study will provide evidence on the efficacy and safety of electroacupuncture plus warm needling therapy as an alternative treatment method for heel pain. The findings will determine whether the treatment protocol is efficacious in relieving pain and improving foot function among older adults with heel pain. The study will also provide information for subsequent large-scale randomized controlled trials in the future.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1800014906 . Registered on 12 February 2018.

Effectiveness of Foot Orthoses Versus Corticosteroid Injection for Plantar Heel Pain: The SOOTHE Randomized Clinical Trial

BACKGROUND

Plantar heel pain is a common foot complaint that causes significant disability and poorer health-related quality of life. Foot orthoses and corticosteroid injection are effective treatments for plantar heel pain; however, it is unclear whether one is more effective than the other.

OBJECTIVE

The aim of this trial was to compare the effectiveness of foot orthoses and corticosteroid injection for plantar heel pain.

METHODS

In this parallel-group, assessor-blinded, randomized clinical trial, participants received prefabricated, arch-contouring foot orthoses or a single ultrasound-guided corticosteroid injection. The primary outcome measure was the foot pain subscale of the Foot Health Status Questionnaire at 4 and 12 weeks.

RESULTS

One hundred three participants aged 21 to 72 years (63 female) with plantar heel pain were recruited from the community and received an intervention. For the primary outcome of foot pain, corticosteroid injection was more effective at week 4 (adjusted mean difference, 8.2 points; 95% confidence interval: 0.6, 15.8 points). However, foot orthoses were more effective at week 12 (adjusted mean difference, 8.5 points; 95% confidence interval: 0.2, 16.8 points). Although these findings were statistically significant, the differences between the interventions did not meet the previously calculated minimal important difference value of 12.5 points.

CONCLUSION

Corticosteroid injection is more effective than foot orthoses at week 4, but this effect does not last; and appropriately contoured foot orthoses are more effective than corticosteroid injection at week 12. However, patients may not notice a clinically worthwhile difference between the interventions.

LEVEL OF EVIDENCE

Therapy, level 1b. J Orthop Sports Phys Ther 2019;49(7):491-500. Epub 26 May 2019. doi:10.2519/jospt.2019.8807.

Plantar fasciitis treated with endoscopic partial plantar fasciotomy-One-year clinical and ultrasonographic follow-up

BACKGROUND

Endoscopic operations for plantar fasciitis generally have good clinical outcome. The aim of this study was to record the effect of endoscopic partial fasciotomy and heel spur removal and evaluate by ultrasonography whether the fascia regenerates and the heel spur reforms.

METHODS

Eleven consecutive patients were evaluated before and 3, 6 and 12 months after surgery. Operations were performed endoscopically using a deep fascial approach with a medial and a lateral portal. Bony spurs were removed and the medial half of the plantar fascia was transected. All patients followed a standardized rehabilitation program.

RESULTS

Median Foot Function Index values decreased from 119 pre-surgery to 69 and 12 (p=0.004), at 3 months and 1year post-operatively respectively. Median VAS-score for first step pain was likewise reduced from median 71mm to 29mm and 7mm (p=0.004), respectively. Median fascial thickness at the medial insertion was 6.0mm (range 4.6-6.8mm) pre-operatively. A heel spur was present in 9 cases. One year postoperatively a well-defined fascia in the area of resection was demonstrated in 8 cases. In the rest of the cases scar tissue made it impossible to clearly outline the fascia. Nine of the feet showed good medial fascial tensioning. There was no evidence of recurrence of the bony spur.

CONCLUSIONS

Endoscopic partial plantar fascia resection reduced pain symptoms and increased function significantly 3 months after operation, with additional effect achieved 12 months after surgery. Based on ultrasonography the resected fascia regenerated/healed, and a calcaneal spur did not recur.

Quality of life related to foot health status in women with fibromyalgia: a case-control study

INTRODUCTION

To date, the Foot Health Status Questionnaire (FHSQ) has not been applied to women who suffer from fibromyalgia. The main purpose of this study was to compare both foot and general health-related quality of life between women with fibromyalgia and healthy matched women. We hypothesized that women with fibromyalgia may present an impaired quality of life related to foot and general health.

MATERIAL AND METHODS

A sample of 208 women, mean age of 55.00 ±8.25 years, was recruited from an outpatient clinic and divided into 2 groups, 104 women with fibromyalgia (for the case group) and 104 healthy matched women (for the control group). Demographic data and the domains of the FHSQ scores were registered.

RESULTS

Statistically significant differences (p < 0.001) between case and control groups were found for both all specific foot domains (pain, foot function, foot health and footwear) and all general wellbeing domains (general health, physical activity, social capacity and vigor), showing a worse foot and general health-related quality of life (with lower scores for all FHSQ domains) in the women with fibromyalgia compared to healthy matched women.

CONCLUSIONS

Impaired foot and general health-related quality of life was observed in women who suffered from fibromyalgia compared to healthy matched women.

Effects of forefoot arthroplasty on plantar pressure, pain, gait and disability in rheumatoid arthritis

Objectives: The purpose of this study was to clarify the effect of forefoot arthroplasty on plantar pressure, pain, gait, and disability within 1 year after arthroplasty in patients with RA.Methods: Eleven patients with RA who underwent forefoot arthroplasty completed this quasi-experimental study. Outcome measures were in-shoe plantar pressure, visual analog scale (VAS) for pain, temporal gait parameters, and modified Health Assessment Questionnaire (mHAQ), obtained preoperatively and at 4 and 12 months postoperatively.Results: The average peak plantar pressure under the 2nd metatarsal head decreased at 4 months postoperatively, compared to preoperative values (p < .05) and the decreased plantar pressure was sustained at 12 months postoperatively. Similar changes were observed under the 3rd to 5th metatarsal heads. The median VAS for foot pain decreased from 25 mm preoperatively to 1 mm at 4 months postoperatively and the lower score was sustained at 12 months postoperatively (p < .05). The median mHAQ score remained lower (<1.0) at all measurement points. Regarding gait, there were no significant differences from the preoperative assessment to postoperative follow-up.Conclusion: Plantar pressure and forefoot pain decreased at 4 and 12 months after forefoot arthroplasty in patients with RA. No adverse effects on gait parameters or disability were observed.

Effect of generalized ligamentous hyperlaxity related of quality of life in the foot: a case controlled study

Generalized ligamentous hyperlaxity (GLH) has been shown to predispose an individual to a number of orthopaedic conditions. Little is known about how GLH affects people' foot health-related quality of life. This study analyses a sample of people with GLH and people without GLH with normalised reference values of the scores collected with regard to using the Foot Health Status Questionnaire (FSHQ). A total of 100 respondents with mean age of 22.69 ± 3.78 years old, who attended a health centre were classified as GLH (n = 50) or non-GLH (n = 50). The GLH was determined of the patients with and without GLH using assessment with Beighton tool and the scores on the FHSQ were compared. The control group recorded higher scores in the First Section for foot pain, foot function and general foot health, and lower scores in footwear. In the Second Section, they obtained higher scores in social capacity and lower scores in physical activity, vigour and general health. Differences between the two groups were evaluated through a t-test for independent samples, showing statistical significance (P<0.001). This study has detected measurable differences of association between GLH (Beighton score ≥4) with impaired quality of life related to foot health.

Electrical dry needling as an adjunct to exercise, manual therapy and ultrasound for plantar fasciitis: A multi-center randomized clinical trial

Study Design

Randomized, single-blinded, multi-center, parallel-group trial.

Objectives

To compare the effects of adding electrical dry needling into a program of manual therapy, exercise and ultrasound on pain, function and related-disability in individuals with plantar fasciitis (PF).

Background

The isolated application of electrical dry needling, manual therapy, exercise, and ultrasound has been found to be effective for PF. However, no previous study has investigated the combined effect of these interventions in this population.

Methods

One hundred and eleven participants (n = 111) with plantar fasciitis were randomized to receive electrical dry needling, manual therapy, exercise and ultrasound (n = 58) or manual therapy, exercise and ultrasound (n = 53). The primary outcome was first-step pain in the morning as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included resting foot pain (NPRS), pain during activity (NPRS), the Lower Extremity Functional Scale (LEFS), the Foot Functional Index (FFI), medication intake, and the Global Rating of Change (GROC). The treatment period was 4 weeks with follow-up assessments at 1 week, 4 weeks, and 3 months after the first treatment session. Both groups received 6 sessions of impairment-based manual therapy directed to the lower limb, self-stretching of the plantar fascia and the Achilles tendon, strengthening exercises for the intrinsic muscles of the foot, and therapeutic ultrasound. In addition, the dry needling group also received 6 sessions of electrical dry needling using a standardized 8-point protocol for 20 minutes. The primary aim was examined with a 2-way mixed-model analysis of covariance (ANCOVA) with treatment group as the between-subjects variable and time as the within-subjects variable after adjusting for baseline outcomes.

Results

The 2X4 ANCOVA revealed that individuals with PF who received electrical dry needling, manual therapy, exercise and ultrasound experienced significantly greater improvements in first-step morning pain (F = 22.021; P<0.001), resting foot pain (F = 23.931; P<0.001), pain during activity (F = 7.629; P = 0.007), LEFS (F = 13.081; P<0.001), FFI Pain Subscale (F = 13.547; P<0.001), FFI Disability Subscale (F = 8.746; P = 0.004), and FFI Total Score (F = 10.65; P<0.001) than those who received manual therapy, exercise and ultrasound at 3 months. No differences in FFI Activity Limitation Subscale (F = 2.687; P = 0.104) were observed. Significantly (X² = 9.512; P = 0.023) more patients in the electrical dry needling group completely stopped taking medication for their pain compared to the manual therapy, exercise and ultrasound group at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X² = 45.582; P<0.001) more patients within the electrical dry needling group (n = 45, 78%) achieved a successful outcome compared to the manual therapy, exercise and ultrasound group (n = 11, 21%). Effect sizes ranged from medium to large (0.53<SMD<0.85) at 3 months in favor of the electrical dry needling group.

Conclusion

The inclusion of electrical dry needling into a program of manual therapy, exercise and ultrasound was more effective for improving pain, function and related-disability than the application of manual therapy, exercise and ultrasound alone in individuals with PF at mid-term (3 months).

Level of evidence

Therapy, Level 1b.

The effect of isometric exercise on pain in individuals with plantar fasciopathy: A randomized crossover trial

Isometric exercise is commonly recommended for immediate pain relief in individuals suffering from lower limb tendinopathies, despite the limited evidence supporting its analgesic effect. Due to the similarities between plantar fasciopathy and tendinopathies, the aim of this trial was to investigate the acute effect of isometric exercise on pain, compared to isotonic exercise, or walking, in individuals with plantar fasciopathy. We recruited 20 individuals with plantar fasciopathy for this prospectively-registered, participant-blinded, randomized, superiority crossover trial (ClinicalTrials.gov: NCT03264729). Participants attended three exercise sessions (isometric, isotonic, or walking) in a randomized order, within a 2-week period. Both isometric and isotonic exercises were performed standing with the forefoot on a step bench, while walking was performed barefoot. The primary outcome was pain (measured on a 0-100-mm VAS) during a pain-aggravating activity. Secondary outcomes included pressure pain threshold (PPT) under the heel, and plantar fascia thickness (PFT). All outcomes were measured before and after each exercise session. There were no significant differences between the three exercises on pain (P = 0.753), PPTs (P = 0.837), or PFT (P = 0.718). Further, there was no change in pain from before to after any of the exercises (isometric exercise 2.7 mm [95% CI: -12.2; 6.8], isotonic exercise -3.4 mm [95% CI: -5.0; 11.8], or walking 1.6 mm [95% CI: -16.1; 12.9]). Contrary to expectations, isometric exercise was no better than isotonic exercise or walking at reducing pain in individuals with plantar fasciopathy. None of the exercises induced any systematic analgesic effect.

Clinical effectiveness of multi-wavelength photobiomodulation therapy as an adjunct to extracorporeal shock wave therapy in the management of plantar fasciitis: a randomized controlled trial

The goal of our study was to investigate the cumulative effect of combining medium-energy extracorporeal shock wave therapy (ESWT) and photobiomodulation therapy (PBMT), as well as to compare between their relative effectiveness in the management of plantar fasciitis (PF). One hundred twenty participants with chronic PF, more than 6 months with failure to respond to conservative treatment, were randomly assigned into four equal groups. Participants received either ESWT with PBMT, ESWT (once a week), PBMT (three times a week), or sham-PBMT (three times a week) for three consecutive weeks. A home exercise program was also included for all four groups. Outcome measures included pressure pain threshold (PPT), visual analogue scale (VAS), and functional foot index disability subscale (FFI-d) that were collected prior to the first treatment session and at the end of the 3-week treatment period, as well as at a follow-up session, 12 weeks after the final treatment session. There were statistically significant improvements in post-intervention and follow-up PPT, VAS, and FFI-d values in all treatment groups (P < 0.0001). As for the sham-PBMT, no significant difference was found between the pre-, post-intervention and follow-up values (P > 0.05). Bonferroni correction test revealed that there was a significant difference between all the four groups in PPT, VAS, and FFI-d values (P < 0.0001). All active treatment groups maintained the treatment effect at the 12-week follow-up. Both ESWT and PBMT were effective in increasing PPT values, decreasing pain and increasing functional ability. Additionally, application of PBMT after ESWT was shown to be superior over ESWT and PBMT alone, and ESWT was superior over PBMT in terms of reducing pain sensitivity and increasing function.Level of Evidence II.

Efficacy of platelet-rich plasma as conservative treatment in orthopaedics: a systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to evaluate the benefit of platelet-rich plasma (PRP) in non-surgical orthopaedic procedures.

MATERIAL AND METHODS

We searched the Cochrane Wounds Specialized Register, CENTRAL, MEDLINE (through PUBMED), Embase, and SCOPUS. We also searched clinical trials registries for ongoing and unpublished studies and checked reference lists to identify additional studies.

RESULTS

We found 36 randomised controlled trials (2,073 patients) that met our inclusion criteria. The included studies mostly had small numbers of participants (from 20 to 225). Twenty-eight studies included patients with lateral epicondylitis or plantar fasciitis. PRP was compared to local steroids injection (19 studies), saline injection (6 studies), autologous whole blood (4 studies), local anaesthetic injection (3 studies), dry needling injection (3 studies), and to other comparators (4 studies). Primary outcomes were pain and function scores, and adverse events. On average, it is unclear whether or not use of PRP compared to controls reduces pain scores and functional score at short- (up to 3 months) and medium- (4-6 months) term follow-up. The available evidence for all the comparisons was rated as very low quality due to inconsistency, imprecision, and risk of bias in most of the selected studies. There were no serious adverse events related to PRP injection or control treatments.

CONCLUSIONS

The results of this meta-analysis, which documents the very marginal effectiveness of PRP compared to controls, does not support the use of PRP as conservative treatment in orthopaedics.

Specific foot health-related quality-of-life impairment in patients with type II versus type I diabetes

The aims of this research were to evaluate and compare the effect in a matched sample of patients with type II and type I diabetes scores using a specific quality-of-life (QoL) tool related to overall and foot health (Foot Health Status Questionnaire [FHSQ]). A sample of 62 patients with an age median of 59.00 ± 19.00 y were divided into type I (n = 31) and type II (n = 31) diabetes groups. Socio-demographics data include: (1) age, (2) gender, (3) body mass index, (4) professional activity, (5) study level, and (6) civil status. The FHSQ was used to evaluate foot (pain, function, footwear, and general health section I domains) and overall (general health, social capacity, physical activity, and vigour section II domains) health related to QoL. Differences between groups were assessed by means of a t test or Mann-Whitney U test for independent samples. There were no statistically significant differences (P > 0.05) for any socio-demographic data. Regarding the FHSQ section II of the specific foot health-related QoL, the only statistically significant differences (P = 0.042) were observed for the general foot health showing a QoL impairment (lower median ± interquartile range) in patients diagnosed with type II diabetes (60.00 ± 60.00 points) compared with patients who suffered from type I diabetes (25.00 ± 72.50 points). The other domains did not show any statistically significant differences (P > 0.05). Patients with type II diabetes present a negative impact on the specific foot health-related QoL compared with patients who suffered from type I diabetes.

Custom foot orthoses improve first-step pain in individuals with unilateral plantar fasciopathy: a pragmatic randomised controlled trial

BACKGROUND

Foot orthoses are routinely used to treat plantar fasciopathy in clinical practice. However, minimal evidence exists as to the effect of both truly custom designed foot orthoses, as well as that of the shoe the foot orthoses are placed into. This study investigated the effect of wearing custom foot orthoses and new athletic footwear on first-step pain, average 24-h pain and plantar fascia thickness in people with unilateral plantar fasciopathy over 12 weeks.

METHODS

A parallel, three-arm randomised controlled trial with blinding of participants and assessors. 60 participants diagnosed with unilateral plantar fasciopathy were randomised to either custom foot orthoses and new shoes (orthoses group), a sham insole with a new shoes (shoe group) or a sham insole placed in the participant's regular shoes (control group). Primary outcome was first-step pain. Secondary outcomes were average 24-h pain and plantar fascia thickness measured on ultrasound. Outcomes were assessed at baseline, 4 week and 12 week trial time-points.

RESULTS

At 4 weeks, the orthoses group reported less first-step pain (p = 0.002) compared to the control group. At 12 weeks, the orthoses group reported less first-step pain compared to both the shoe (p = < 0.001) and sham (p = 0.01) groups. Both the orthoses (p = < 0.001) and shoe (p = 0.006) groups reported less average 24-h pain compared to the control group at 4 and 12 weeks. The orthoses group demonstrated reduced plantar fascia thickness on ultrasound compared to both the shoe (p = 0.032) and control groups (p = 0.011).

CONCLUSIONS

Custom foot orthoses in new shoes improve first-step pain and reduce plantar fascia thickness over a period of 12 weeks compared to new shoes alone or a sham intervention.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ( ACTRN 12613000446763 ). Submitted on the 10th of April 2013 and registered on the 18th of April 2013.

Complication Rates and Short-Term Outcomes After Operative Hammertoe Correction in Older Patients

BACKGROUND

Hammertoe deformities are the most common lesser toe deformity. To date, no studies have looked at outcomes of operative management in the geriatric population, which may be at greater risk for complications or functional compromise because of comorbidities.

METHODS

Data on 58 patients undergoing operative correction of hammertoe deformities were prospectively collected. Clinical outcomes were assessed using preoperative and postoperative visual analogue scale (VAS) and Short Form Health Survey (SF-36) scores with a minimum of 6-month follow-up. Patients were divided into 2 groups on the basis of age at the time of surgery: younger than 65 and 65 and older. Complication rates and mean VAS and SF-36 improvement were compared. Forty-seven patients met inclusion criteria (7 men, 40 women), with 26 patients (37 toes) in the younger cohort and 21 patients (39 toes) in the older cohort.

RESULTS

Overall, patients demonstrated significant improvement from baseline to 6 and 12 months postoperatively in VAS ( P < .001 and P < .001) and SF-36 ( P < .001 and P < .001) scores. Mean improvement in VAS and SF-36 scores was not significantly different between the groups at 6 and 12 months postoperatively. Complications occurred in 13.5% and 10.3% of patients in the younger and older cohorts, respectively.

CONCLUSIONS

Outcomes of operative correction of hammertoe deformities in older patients were similar to outcomes in younger patients after greater than 6 months of follow-up. Overall improvement in VAS and SF-36 was statistically significant for both cohorts. There was no associated increase in complications for older patients.

LEVEL OF EVIDENCE

Level, III comparative series.

Combination Therapy Versus Exercise and Orthotic Support in the Management of Pain in Plantar Fasciitis: A Randomized Controlled Trial

BACKGROUND

This study aimed at estimating the effectiveness of two commonly used modalities-extracorporeal shock wave therapy (ESWT) and low-level laser therapy (LLLT)-each combined with usual care (exercises and orthotic supports) in comparison to only usual care to relieve pain in patients with plantar fasciitis (PF).

METHODS

Participants with PF were randomly allocated into 3 groups: ESWT (n = 25), LLLT (n = 24), and control (n = 17). All participants received a home exercise program with orthotic support. The ESWT group received 2000 shock waves with 0.02 mJ/mm² for 3 sessions, once a week; LLLT group received gallium-aluminum-arsenide laser with 850 nm wavelength for 10 sessions, 3 times a week. Pain was measured by Foot Function Index-pain subscale (FFI-p) and Numerical Rating Scale for pain (NRS-p). The scores were recorded at baseline, third week, and third month after the treatment. Analysis was performed using repeated measures ANOVA.

RESULTS

There was a significant improvement in pain over the 3 months in all groups on both FFI-p ( P < .001) and NRS-p ( P < .001). In NRS-p, LLLT group had significantly lower pain than ESWT ( P = .002) at the third week and control ( P = .043) and ESWT ( P = .003) at third month. In FFI-p total score, ESWT group had higher pain than LLLT ( P = .003) and control ( P = .035) groups at third week and LLLT ( P = .010) group at third month.

CONCLUSION

When LLLT and ESWT were combined with usual care, LLLT was found to be more effective than ESWT in reducing pain in PF at short-term follow-up.

LEVEL OF EVIDENCE

Level II, comparative study.

Efficacy of foot orthoses for the treatment of plantar heel pain: a systematic review and meta-analysis

BACKGROUND

Plantar heel pain (PHP) is common. Foot orthoses are often applied as treatment for PHP, even though there is little evidence to support this.

OBJECTIVE

To investigate the effects of different orthoses on pain, function and self-reported recovery in patients with PHP and compare them with other conservative interventions.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A systematic literature search was conducted in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL and Google Scholar up to January 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing foot orthoses with a control (defined as no intervention, sham or other type of conservative treatment) reporting on pain, function or self-reported recovery in patients with PHP.

RESULTS

Twenty studies investigating eight different types of foot orthoses were included in the review. Most studies were of high quality. Pooled data from six studies showed no difference between prefabricated orthoses and sham orthoses for pain at short term (mean difference (MD) of 0.26 (95% CI -0.09 to 0.60)). No difference was found between sham orthoses and custom orthoses for pain at short term (MD 0.22 (95% CI -0.05 to 0.50)), nor was there a difference between prefabricated orthoses and custom orthoses for pain at short term (MD 0.03 (95% CI -0.15 to 0.22)). For the majority of other interventions, no significant differences were found.

CONCLUSIONS

Foot orthoses are not superior for improving pain and function compared with sham or other conservative treatment in patients with PHP.

PROSPERO REGISTRATION NUMBER

CRD42015029659.

Foot orthoses for plantar heel pain: a systematic review and meta-analysis

Objective

To investigate the effectiveness of foot orthoses for pain and function in adults with plantar heel pain.

Design

Systematic review and meta-analysis. The primary outcome was pain or function categorised by duration of follow-up as short (0 to 6 weeks), medium (7 to 12 weeks) or longer term (13 to 52 weeks).

Data sources

Medline, CINAHL, SPORTDiscus, Embase and the Cochrane Library from inception to June 2017.

Eligibility criteria for selecting studies

Studies must have used a randomised parallel-group design and evaluated foot orthoses for plantar heel pain. At least one outcome measure for pain or function must have been reported.

Results

A total of 19 trials (1660 participants) were included. In the short term, there was very low-quality evidence that foot orthoses do not reduce pain or improve function. In the medium term, there was moderate-quality evidence that foot orthoses were more effective than sham foot orthoses at reducing pain (standardised mean difference −0.27 (−0.48 to −0.06)). There was no improvement in function in the medium term. In the longer term, there was very low-quality evidence that foot orthoses do not reduce pain or improve function. A comparison of customised and prefabricated foot orthoses showed no difference at any time point.

Conclusion

There is moderate-quality evidence that foot orthoses are effective at reducing pain in the medium term, however it is uncertain whether this is a clinically important change.

The symptomatic and functional effects of manual physical therapy on plantar heel pain: a systematic review

OBJECTIVES

Plantar heel pain is common and can be severely disabling. Unfortunately, a gap in the literature exists regarding the optimal intervention for this painful condition. Consequently, a systematic review of the current literature regarding manual therapy for the treatment of plantar heel pain was performed.

METHODS

A computer-assisted literature search for randomized controlled trials in MEDLINE, EMBASE, Cochrane, CINAHL, and Rehabilitation & Sports Medicine Source, was concluded on 7 January 2014. After identification of titles, three independent reviewers selected abstracts and then full-text articles for review.

RESULTS

Eight articles were selected for the final review and underwent PEDro scale assessment for quality. Heterogeneity of the articles did not allow for quantitative analysis. Only two studies scored ≥7/10 on the PEDro scale and included joint, soft tissue, and neural mobilization techniques. These two studies showed statistically greater symptomatic and functional outcomes in the manual therapy group.

DISCUSSION

This review suggests that manual therapy is effective in the treatment of plantar heel pain; however, further research is needed to validate these findings given the preponderance of low quality studies.

Injected corticosteroids for treating plantar heel pain in adults

BACKGROUND

Plantar heel pain, commonly resulting from plantar fasciitis, often results in significant morbidity. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), orthoses, physical therapy, physical agents (e.g. extracorporeal shock wave therapy (ESWT), laser) and invasive procedures including steroid injections.

OBJECTIVES

To assess the effects (benefits and harms) of injected corticosteroids for treating plantar heel pain in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, CINAHL, clinical trials registries and conference proceedings. Latest search: 27 March 2017.

SELECTION CRITERIA

Randomised and quasi-randomised trials of corticosteroid injections in the treatment of plantar heel pain in adults were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected studies, assessed risk of bias and extracted data. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcome measures. We used a fixed-effect model unless heterogeneity was significant, when a random-effects model was considered. We assessed the overall quality of evidence for individual outcomes using the GRADE approach.

MAIN RESULTS

We included a total of 39 studies (36 randomised controlled trials (RCTs) and 3 quasi-RCTs) that involved a total of 2492 adults. Most studies were small (median = 59 participants). Participants' mean ages ranged from 34 years to 59 years. When reported, most participants had heel pain for several months. The trials were usually conducted in outpatient specialty clinics of tertiary care hospitals in 17 countries. Steroid injection was given with a local anaesthetic agent in 34 trials. Follow-up was from one month to over two years. With one exception, trials were assessed at high risk of bias in one or more domains, mostly relating to lack of blinding, including lack of confirmation of allocation concealment. With two exceptions, we rated the available evidence as very low quality, implying in each case that we are 'very uncertain about the estimate'.The 39 trials covered 18 comparisons, with six of the seven trials with three or four groups providing evidence towards two comparisons.Eight trials (724 participants) compared steroid injection versus placebo or no treatment. Steroid injection may lead to lower heel pain visual analogue scores (VAS) (0 to 100; higher scores = worse pain) in the short-term (< 1 month) (MD -6.38, 95% CI -11.13 to -1.64; 350 participants; 5 studies; I² = 65%; low quality evidence). Based on a minimal clinically significant difference (MCID) of 8 for average heel pain, the 95% CI includes a marginal clinical benefit. This potential benefit was diminished when data were restricted to three placebo-controlled trials. Steroid injection made no difference to average heel pain in the medium-term (1 to 6 months follow-up) (MD -3.47, 95% CI -8.43 to 1.48; 382 participants; 6 studies; I² = 40%; low quality evidence). There was very low quality evidence for no effect on function in the medium-term and for an absence of serious adverse events (219 participants, 4 studies). No studies reported on other adverse events, such as post-injection pain, and on return to previous activity. There was very low quality evidence for fewer treatment failures (defined variously as persistent heel pain at 8 weeks, steroid injection at 12 weeks, and unrelieved pain at 6 months) after steroid injection.The available evidence for other comparisons was rated as very low quality. We are therefore very uncertain of the estimates for the relative effects on people with heel pain of steroids compared with other interventions in:1. Tibial nerve block with anaesthetic (2 trials); orthoses (4 trials); oral NSAIDs (2 trials); and intensive physiotherapy (1 trial).2. Physical modalities: ESWT (5 trials); laser (2 trials); and radiation therapy (1 trial).3. Other invasive procedures: locally injectable NSAID (1 trial); platelet-rich plasma injections (5 trials); autologous blood injections (2 trials); botulinum toxin injections (2 trials); cryopreserved human amniotic membrane injection (1 trial); localised peppering with a needle (1 trial); dry needling (1 trial); and mini scalpel needle release (1 trial).We are also uncertain about the estimates from trials testing different techniques of local steroid injection: ultrasonography-guided versus palpation-guided (5 trials); and scintigraphy-guided versus palpation-guided (1 trial).An exploratory analysis involving pooling data from 21 trials reporting on adverse events revealed two ruptures of plantar fascia (reported in 1 trial) and three injection site infections (reported in 2 trials) in 699 participants allocated to steroid injection study arms. Five trials reported a total of 27 participants with less serious short-term adverse events in the 699 participants allocated steroid injection study arms. Reported treatments were analgesia, ice or both. Given the high risk of selective reporting for these outcomes and imprecision, this evidence was rated at very low quality.

AUTHORS' CONCLUSIONS

We found low quality evidence that local steroid injections compared with placebo or no treatment may slightly reduce heel pain up to one month but not subsequently. The available evidence for other outcomes of this comparison was very low quality. Where available, the evidence from comparisons of steroid injections with other interventions used to treat heel pain and of different methods of guiding the injection was also very low quality. Although serious adverse events relating to steroid injection were rare, these were under-reported and a higher risk cannot be ruled out.Further research should focus on establishing the effects (benefits and harms) of injected steroids compared with placebo in typical clinical settings, subsequent to a course of unsuccessful conservative therapy. Ideally, this should be preceded by research, including patient involvement, aimed to obtain consensus on the priority questions for treating plantar heel pain.

Minimal Clinically Important Differences for American Orthopaedic Foot & Ankle Society Score in Hallux Valgus Surgery

BACKGROUND

The American Orthopaedic Foot & Ankle Society (AOFAS) score is one of the most common and adapted outcome scales in hallux valgus surgery. However, AOFAS is predominantly physician based and not patient based. Although it may be straightforward to derive statistical significance, it may not equate to the true subjective benefit of the patient's experience. There is a paucity of literature defining MCID for AOFAS in hallux valgus surgery although it could have a great impact on the accuracy of analyzing surgical outcomes. Hence, the primary aim of this study was to define the Minimal Clinically Important Difference (MCID) for the AOFAS score in these patients, and the secondary aim was to correlate patients' demographics to the MCID.

METHODS

We conducted a retrospective cross-sectional study. A total of 446 patients were reviewed preoperatively and followed up for 2 years. An anchor question was asked 2 years postoperation: "How would you rate the overall results of your treatment for your foot and ankle condition?" (excellent, very good, good, fair, poor, terrible). The MCID was derived using 4 methods, 3 from an anchor-based approach and 1 from a distribution-based approach. Anchor-based approaches were (1) mean difference in 2-year AOFAS scores of patients who answered "good" versus "fair" based on the anchor question; (2) mean change of AOFAS score preoperatively and at 2-year follow-up in patients who answered good; (3) receiver operating characteristic (ROC) curves method, where the area under the curve (AUC) represented the likelihood that the scoring system would accurately discriminate these 2 groups of patients. The distribution-based approach used to calculate MCID was the effect size method. There were 405 (90.8%) females and 41 (9.2%) males. Mean age was 51.2 (standard deviation [SD] = 13) years, mean preoperative BMI was 24.2 (SD = 4.1).

RESULTS

Mean preoperative AOFAS score was 55.6 (SD = 16.8), with significant improvement to 85.7 (SD = 14.4) in 2 years ( P value < .001). There were no statistical differences between demographics or preoperative AOFAS scores of patients with good versus fair satisfaction levels. At 2 years, patients who had good satisfaction had higher AOFAS scores than fair satisfaction (83.9 vs 78.1, P < .001) and higher mean change (30.2 vs 22.3, P = .015). Mean change in AOFAS score in patients with good satisfaction was 30.2 (SD = 19.8). Mean difference in good versus fair satisfaction was 7.9. Using ROC analysis, the cut-off point is 29.0, with an area under the curve (AUC) of 0.62. Effect size method derived an MCID of 8.4 with a moderate effect size of 0.5. Multiple linear regression demonstrated increasing age (β = -0.129, CI = -0.245, -0.013, P = .030) and higher preoperative AOFAS score (β = -0.874, CI = -0.644, -0.081, P < .001) to significantly decrease the amount of change in the AOFAS score.

CONCLUSION

The MCID of AOFAS score in hallux valgus surgery was 7.9 to 30.2. The MCID can ensure clinical improvement from a patient's perspective and also aid in interpreting results from clinical trials and other studies.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Shoe-stiffening inserts for first metatarsophalangeal joint osteoarthritis (the SIMPLE trial): study protocol for a randomised controlled trial

BACKGROUND

This article describes the design of a parallel-group, participant- and assessor-blinded randomised controlled trial comparing the effectiveness of shoe-stiffening inserts versus sham shoe insert(s) for reducing pain associated with first metatarsophalangeal joint (MTPJ) osteoarthritis (OA).

METHODS

Ninety participants with first MTPJ OA will be randomised to receive full-length shoe-stiffening insert(s) (Carbon Fibre Spring Plate, Paris Orthotics, Vancouver, BC, Canada) plus rehabilitation therapy or sham shoe insert(s) plus rehabilitation therapy. Outcome measures will be obtained at baseline, 4, 12, 24 and 52 weeks; the primary endpoint for assessing effectiveness being 12 weeks. The primary outcome measure will be the foot pain domain of the Foot Health Status Questionnaire (FHSQ). Secondary outcome measures will include the function domain of the FHSQ, severity of first MTPJ pain (using a 100-mm Visual Analogue Scale), global change in symptoms (using a 15-point Likert scale), health status (using the Short-Form-12® Version 2.0 and EuroQol (EQ-5D-5L™) questionnaires), use of rescue medication and co-interventions, self-reported adverse events and physical activity levels (using the Incidental and Planned Activity Questionnaire). Data will be analysed using the intention-to-treat principle. Economic analysis (cost-effectiveness and cost-utility) will also be performed. In addition, the kinematic effects of the interventions will be examined at 1 week using a three-dimensional motion analysis system and multisegment foot model.

DISCUSSION

This study will determine whether shoe-stiffening inserts are a cost-effective intervention for relieving pain associated with first MTPJ OA. The biomechanical analysis will provide useful insights into the mechanism of action of the shoe-stiffening inserts.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, identifier: ACTRN12616000552482 . Registered on 28 April 2016.

Corticosteroid injections compared to foot orthoses for plantar heel pain: protocol for the SOOTHE heel pain randomised trial

INTRODUCTION

Corticosteroid injections and foot orthoses are common interventions for plantar heel pain. Previous clinical trials have found that the effectiveness of these interventions differs over time, with corticosteroid injections being more effective in the short-term (i.e. 0-4 weeks) and foot orthoses more effective in the longer-term (i.e. 5-12 weeks). However, some of these trials have methodological weaknesses that could have caused confounding and bias, which may have led to over- or under-estimation of the effectiveness of these interventions. As a result, there is a need to compare the effectiveness of corticosteroid injections and foot orthoses in a robust clinical trial with an appropriate follow-up time.

METHODS

This article describes the protocol for a pragmatic, parallel-group assessor-blinded randomised trial (Steroid injection versus foot orthoses (SOOTHE) heel pain trial). One hundred participants with plantar heel pain will be randomly allocated (i.e. two groups of approximately 50) to receive either an ultrasound-guided corticosteroid injection or prefabricated foot orthoses. Outcome measures will be obtained at baseline, 4, 8 and 12 weeks, with two primary endpoints at 4 and 12 weeks to reflect the hypothesised temporal effects of each intervention. The primary outcome measure will be the foot pain domain of the Foot Health Status Questionnaire.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry number ACTRN12615001266550.

Combination of Hip Strengthening and Manipulative Therapy for the Treatment of Plantar Fasciitis: A Case Report

OBJECTIVE

The purpose of this case report is to describe the management of using a combination of hip strengthening and manipulative therapy (MT) for a patient with plantar fasciitis.

CLINICAL FEATURES

A 44-year-old patient reported heel pain for approximately 1 year before treatment. The patient reported plantar heel pain and tenderness at the calcaneal tuberosity. The pain was most noticeable in the morning but was reduced after a 30-minute walk. A diagnosis of plantar fasciitis was made at the initial assessment.

INTERVENTION AND OUTCOMES

Initially, a clinical evaluation was performed to measure pain intensity (Numeric Pain Rating Scale), pressure-pain threshold (algometry), and perceived exertion (OMNI Resistance Exercise Scale). The patient then underwent 10 sessions of hip strengthening and MT over a period of 3 months. After the treatment, the intensity of pain and the pressure-pain threshold was reevaluated. The patient reported an improvement in pain intensity (baseline score = 6 vs final score = 1) and an increase in the pressure-pain threshold (initial score = 2.6 vs final score = 7.1). Perceived exertion was also improved after hip muscle strength training (initial score = 10 vs final score = 8).

CONCLUSION

The combination of hip strengthening and MT improved foot pain in a patient with a clinical diagnosis of plantar fasciitis.

Minimally important difference of the Child Oral Health Impact Profile for children with orofacial anomalies

Background

The Child Oral Health Impact Profile (COHIP) is an instrument designed to measure the self-reported oral health-related quality of life of children between the ages of 8 and 15, including domains for oral health, functional well-being, social-emotional well-being, school environment and self-image. The purpose of this study was to estimate the minimally important difference (MID) of the COHIP for patients with cleft lip/palate.

Methods

Data from a 6-year, prospective, longitudinal cohort study of children with cleft lip/palate were analyzed to estimate the MID. Analysis was restricted to patients with data at baseline and first follow-up and not receiving a surgical intervention in the intervening years (N = 281). MIDs were estimated via the anchor-based method, using the Global Assessment of Change, and the effect size distribution method.

Results

Based on the distributional method, the minimally important differences were 0.16 (oral health), 0.12 (functional), 0.22 (social-emotional), 0.21 (school environment) and 0.19 (self-image). MID anchor estimates for COHIP domains ranged from −0.32 to 0.84. The anchor-based and effect size MID estimates for the overall COHIP score were 2.95 and 0.25, respectively.

Conclusion

The minimally important difference of the Child Oral Health Impact Profile is recommended for interpreting clinically meaningful change in patients with cleft lip/palate.

The Effectiveness of Physical Agents for Lower-Limb Soft Tissue Injuries: A Systematic Review

Study Design Systematic review. Background Soft tissue injuries to the lower limb bring a substantial health and economic burden to society. Physical agents are commonly used to treat these injuries. However, the effectiveness of many such physical agents is not clearly established in the literature. Objective To evaluate the effectiveness and safety of physical agents for soft tissue injuries of the lower limb. Methods We searched 5 databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies. Paired reviewers independently screened the retrieved literature and appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a high risk of bias were excluded. We synthesized low-risk-of-bias studies according to principles of best-evidence synthesis. Results We screened 10261 articles. Of 43 RCTs identified, 20 had a high risk of bias and were excluded from the analysis, and 23 RCTs had a low risk of bias and were included in the analysis. The available higher-quality evidence suggests that patients with persistent plantar fasciitis may benefit from ultrasound or foot orthoses, while those with persistent midportion Achilles tendinopathy may benefit from shockwave therapy. However, the current evidence does not support the use of shockwave therapy for recent plantar fasciitis, low-Dye taping for persistent plantar fasciitis, low-level laser therapy for recent ankle sprains, or splints for persistent midportion Achilles tendinopathy. Finally, evidence on the effectiveness of the following interventions is not established in the current literature: (1) shockwave therapy for persistent plantar fasciitis, (2) cryotherapy or assistive devices for recent ankle sprains, (3) braces for persistent midportion Achilles tendinopathy, and (4) taping or electric muscle stimulation for patellofemoral pain syndrome. Conclusion Almost half the identified RCTs that evaluated the effectiveness of physical agents for the management of lower-limb soft tissue injuries had a high risk of bias. High-quality RCTs are still needed to assess the effectiveness of physical agents for managing the broad range of lower-limb soft tissue injuries. The effectiveness of most interventions remains unclear. Level of Evidence Therapy, 1a. Protocol registered July 10, 2014 with PROSPERO (CRD42014010621). J Orthop Sports Phys Ther 2016;46(7):523-554. Epub 6 Jun 2016. doi:10.2519/jospt.2016.6521.

Effectiveness of Acupuncture Therapies to Manage Musculoskeletal Disorders of the Extremities: A Systematic Review

Study Design Systematic review. Background Little is known about the effectiveness of acupuncture therapies for musculoskeletal disorders. Objective To assess the effectiveness and safety of acupuncture therapies for musculoskeletal disorders of the extremities. Methods We searched MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from 1990 to 2015 for randomized controlled trials, cohort studies, and case-control studies. Eligible studies were appraised with Scottish Intercollegiate Guidelines Network criteria. A best-evidence synthesis was performed to synthesize results from included studies with a low risk of bias. A sensitivity analysis was conducted to determine the impact of excluding studies with a high risk of bias. Results The search revealed 5180 articles; 15 were included (10 with a low risk of bias, 5 with a high risk of bias). The studies with a low risk of bias suggested that (1) traditional needle acupuncture was superior to oral steroids (1 RCT, n = 77) and may be superior to vitamin B1/B6 supplements (1 RCT, n = 64) for carpal tunnel syndrome (CTS), and was superior to exercise for Achilles tendinopathy (1 RCT, n = 64). Traditional needle acupuncture did not provide important benefit over placebo for upper extremity pain (1 RCT, n = 128), or no intervention for patellofemoral pain (1 RCT, n = 75), and was inconclusive for shoulder pain (2 RCTs, n = 849), suggesting no important benefit; (2) electroacupuncture may be superior to placebo for shoulder injuries (1 RCT, n = 130) and may not be superior to night splinting for persistent CTS (1 RCT, n = 78); and (3) dry needling may be superior to placebo for plantar fasciitis (1 RCT, n = 84). Sensitivity analysis suggests that including studies with a high risk of bias might have impacted the evidence synthesis in support of managing shoulder pain with traditional needle acupuncture, and that would suggest traditional needle acupuncture may be effective for lateral epicondylitis and piriformis syndrome. Conclusion Evidence for the effectiveness of acupuncture for musculoskeletal disorders of the extremities was inconsistent. Traditional needle acupuncture may be beneficial for CTS and Achilles tendinopathy, but not for nonspecific upper extremity pain and patellofemoral syndrome. Electroacupuncture may be effective for shoulder injuries and may show similar effectiveness to that of night wrist splinting for CTS. The effectiveness of dry needling for plantar fasciitis is equivocal. Level of Evidence Therapy, 1a-. J Orthop Sports Phys Ther 2016;46(6):409-429. Epub 26 Apr 2016. doi:10.2519/jospt.2016.6270.

The evaluation of three treatments for plantar callus: a three-armed randomised, comparative trial using biophysical outcome measures

BACKGROUND

Callus is one of the most common foot skin complaints experienced by people of all ages. These painful and unsightly lesions often result in disability. The 'gold standard' of treatment is scalpel debridement by a trained specialist; however, people also seek over-the-counter remedies. There is a lack of clinical evidence for the efficacy of such products, which makes selection by patients and practitioners difficult.

METHODS

This randomised, three-armed, parallel, comparative trial aimed to test the efficacy of two home treatments for plantar callus using novel, objective outcome measures (skin hydration using the capacitance method; elasticity using negative pressure application; and surface texture using imaging). Additional outcome measures were: size of callus, quality of life (Foot Health Status Questionnaire) and self-reported participant satisfaction and compliance. The results were compared to a podiatry treatment. Participants were randomly allocated to one of three groups: potassium hydroxide (KOH, 40 %); trichloroacetic acid (TCA); and podiatry treatment. Participants were followed for 3 weeks after their initial intervention appointment (days 7, 14 and 21). The primary outcomes were the change from baseline in callus hydration, elasticity, texture, and size at each of the three time points. The secondary outcomes where: change in quality of life 21 days after treatment; resolution of calluses via visual inspection; and participant compliance and perception.

RESULTS

Forty-six participants (61 ft) with plantar calluses were recruited. The podiatry treatment showed immediate and significant changes in all objective outcomes, associated foot pain and function (p <0.01). Lesser changes in skin quality and perceived pain and functional benefits occurred with TCA and KOH over 21 days.

CONCLUSIONS

This is the first study where objective outcome measures have been used to measure changes in the nature of skin in response to callus treatments. We found significant differences in plantar callus in response to podiatry and two home treatments. The podiatry treatment showed immediate and significant changes in skin and associated foot pain and function. Lesser, but sometimes comparable, changes in skin and perceived pain and functional benefits occurred with TCA and KOH over 21 days.

TRIAL REGISTRATION

ISRCTN14751843 : date of registration: 30 April 2015.

Effectiveness of Foot Orthoses Versus Rocker-Sole Footwear for First Metatarsophalangeal Joint Osteoarthritis: Randomized Trial

OBJECTIVE

To compare the effectiveness of prefabricated foot orthoses to rocker-sole footwear in reducing foot pain in people with first metatarsophalangeal (MTP) joint osteoarthritis (OA).

METHODS

Participants (n = 102) with first MTP joint OA were randomly allocated to receive individualized, prefabricated foot orthoses or rocker-sole footwear. The primary outcome measure was the pain subscale on the Foot Health Status Questionnaire (FHSQ) at 12 weeks. Secondary outcome measures included the function, footwear, and general foot health subscales of the FHSQ; the Foot Function Index; severity of pain and stiffness at the first MTP joint; perception of global improvement; general health status; use of rescue medication and co-interventions to relieve pain; physical activity; and the frequency of self-reported adverse events.

RESULTS

The FHSQ pain subscale scores improved in both groups, but no statistically significant difference between the groups was observed (adjusted mean difference 2.05 points, 95% confidence interval [95% CI] -3.61, 7.71; P = 0.477). However, the footwear group exhibited lower adherence (mean ± SD total hours worn 287 ± 193 versus 448 ± 234; P < 0.001), were less likely to report global improvement in symptoms (39% versus 62%; relative risk [RR] 0.63, 95% CI 0.41, 0.99; P = 0.043), and were more likely to experience adverse events (39% versus 16%; RR 2.47, 95% CI 1.12, 5.44; P = 0.024) compared to the orthoses group.

CONCLUSION

Prefabricated foot orthoses and rocker-sole footwear are similarly effective at reducing foot pain in people with first MTP joint OA. However, prefabricated foot orthoses may be the intervention of choice due to greater adherence and fewer associated adverse events.

DRY NEEDLING IN SUBJECTS WITH MUSCULAR TRIGGER POINTS IN THE LOWER QUARTER: A SYSTEMATIC REVIEW

BACKGROUND

Trigger points, which have been defined as highly localized, hyperirritable locations in a palpable taut band of skeletal muscle fibers, have been identified with a variety of musculoskeletal conditions. The incidence of trigger point pain is high, with studies showing them as the primary source of pain in 30-85% of patients presenting in a primary care setting or pain clinic. Dry needling has emerged as a possible intervention for trigger points, but its effectiveness has not yet fully been determined.

PURPOSE

To assess and provide a summary on the current literature for the use of dry needling as an intervention for lower quarter trigger points in patients with various orthopedic conditions.

STUDY DESIGN

Systematic review.

METHODS

CINAHL, NCBI-PubMed, PEDro, SPORTDiscus, Cochrane Library, and APTA's PTNow were searched to identify relevant randomized controlled trials. Six studies meeting the inclusion criteria were analyzed using the PEDro scale.

RESULTS

Four of the studies assessed by the PEDro scale were deemed 'high' quality and two were 'fair' quality. Each of the six included studies reported statistically significant improvements with dry needling for the reduction of pain intensity in the short-term. Only one study reported a statistically significant improvement in short-term functional outcomes; however, there was no maintenance of improved function at long-term follow-up. Furthermore, none of the studies reported statistically significant changes regarding the effect of dry needling on quality of life, depression, range of motion, or strength.

CONCLUSION

A review of current literature suggests that dry needling is effective in reducing pain associated with lower quarter trigger points in the short-term. However, the findings suggest that dry needling does not have a positive effect on function, quality of life, depression, range of motion, or strength. Further high quality research with long-term follow-up investigating the effect of dry needling in comparison to and in conjunction with other interventions is needed to determine the optimal use of dry needling in treating patients with lower quarter trigger points.

LEVELS OF EVIDENCE

1.

Foot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study

This randomised feasibility study aimed to examine the clinical and biomechanical effects of functional foot orthoses (FFOs) in the treatment of midfoot osteoarthritis (OA) and the feasibility of conducting a full randomised controlled trial. Participants with painful, radiographically confirmed midfoot OA were recruited and randomised to receive either FFOs or a sham control orthosis. Feasibility measures included recruitment and attrition rates, practicality of blinding and adherence rates. Clinical outcome measures were: change from baseline to 12 weeks for severity of pain (numerical rating scale), foot function (Manchester Foot Pain and Disability Index) and patient global impression of change scale. To investigate the biomechanical effect of foot orthoses, in-shoe foot kinematics and plantar pressures were evaluated at 12 weeks. Of the 119 participants screened, 37 were randomised and 33 completed the study (FFO = 18, sham = 15). Compliance with foot orthoses and blinding of the intervention was achieved in three quarters of the group. Both groups reported improvements in pain, function and global impression of change; the FFO group reporting greater improvements compared to the sham group. The biomechanical outcomes indicated the FFO group inverted the hindfoot and increased midfoot maximum plantar force compared to the sham group. The present findings suggest FFOs worn over 12 weeks may provide detectable clinical and biomechanical benefits compared to sham orthoses. This feasibility study provides useful clinical, biomechanical and statistical information for the design and implementation of a definitive randomised controlled trial to evaluate the effectiveness of FFOs in treating painful midfoot OA.

Effect of monophasic pulsed current on heel pain and functional activities caused by plantar fasciitis

BACKGROUND

Plantar fasciitis (PF) is a soft tissue disorder considered to be one of the most common causes of inferior heel pain. The aim of this study was to investigate the effect of monophasic pulsed current (MPC) and MPC coupled with plantar fascia-specific stretching exercises (SE) on the treatment of PF.

MATERIAL AND METHODS

Forty-four participants (22 women and 22 men, with a mean age of 49 years) diagnosed with PF were randomly assigned to receive MPC (n=22) or MPC coupled with plantar fascia-specific SE (n=22). Prior to and after 4 weeks of treatment, participants underwent baseline evaluation; heel pain was evaluated using a visual analogue scale (VAS), heel tenderness threshold was quantified using a handheld pressure algometer (PA), and functional activities level was assessed using the Activities of Daily Living subscale of the Foot and Ankle Ability Measure (ADL/FAAM).

RESULTS

Heel pain scores showed a significant reduction in both groups compared to baseline VAS scores (P<0.001). Heel tenderness improved significantly in both groups compared with baseline PA scores (P<0.001). Functional activity level improved significantly in both groups compared with baseline (ADL/FAAM) scores (P<0.001). However, no significant differences existed between the 2 treatment groups in all post-intervention outcome measures.

CONCLUSIONS

This trial showed that MPC is useful in treating inferior heel symptoms caused by PF.

A comparative efficacy evaluation of ultrasound-guided pulsed radiofrequency treatment in the gastrocnemius in managing plantar heel pain: a randomized and controlled trial

OBJECTIVE

The treatment of plantar heel pain is highly challenging. We report ultrasound-guided pulsed radiofrequency treatment (UG-PRF) in the gastrocnemius to treat plantar heel pain and minimize the safety issues.

DESIGN

This study compared UG-PRF with sham treatment in 100 patients with plantar heel pain. Primary outcome measures include the pain subscale of the Foot Health Status Questionnaire (FHSQ-pain) and "first step" pain as measured on a visual analogue scale (VAS-"first-step" pain). The secondary outcome measures include the FHSQ-foot function and general foot health, and health related quality of life (assessed using the Short Form-36 questionnaire [SF-36]). All outcomes were measured at 3 and 6 months post-treatment.

RESULTS

The results showed the efficacy of UG-PRF in terms of pain management, as reflected by higher FHSQ-pain score (increased by 20.0 (P < 0.0001) and 17.9 (P = 0.001) compared with the sham treatment at 3 or 6 months, respectively) and lower VAS-"first-step" pain (reduced by 26.1 (P < 0.0001) and 14.3 (P = 0.01) compared with the sham group at 3 or 6 months, respectively). The FHSQ-foot function and FHSQ-general foot health were increased by the UG-PRF (P < 0.05, vs sham treatment at 3 or 6 months). The SF-36 physical component score in the sham group was 10.8 (P = 0.042) and 10.4 (P = 0.044) lower than the UG-PRF group at 3 or 6 months, respectively. No severe complications were observed.

CONCLUSIONS

We conclude that the UG-PRF is both safe and efficacious in managing plantar heel pain.

CUPID: a protocol of a randomised controlled trial to identify characteristics of similar Chinese patent medicines

INTRODUCTION

Traditional Chinese medicine (TCM) has accumulated some experience in curing stable angina pectoris (SAP) and efficacy has been demonstrated. Chinese patent medicines, known as modern dosage forms of TCM, can attain the desired effect in clinical application only with the guidance of TCM syndrome theory. However, due to their use by a large number of persons with little knowledge of TCM theories and practices, their efficacy and reputation have been seriously affected.

METHOD AND ANALYSIS

Two common syndrome types of SAP in TCM, 'qi deficiency and blood stasis' and 'qi stagnation and blood stasis', will be studied in 144 subjects from four TCM hospitals in Tianjin in China using a partial crossover design. The two syndromes will be broken down into six symptom combinations; patients will select a combination of the most distressing to them, and then will be randomised into two groups. Each group, on the basis of routine medication, will be administered one kind of Chinese patent drug: Qishenyiqi Dripping Pills or Compound Danshen Dripping Pills. The treatment characteristics of the two medicines will be evaluated with the COME-PIO method developed by our research team.

ETHICS AND DISSEMINATION

This protocol has been approved by the medical ethics committee of Tianjin University of TCM (registration number TJUTCM-EC20130005). The study is safe and reliable.

TRIAL REGISTRATION NUMBER

Chinese clinical trials register ChiCTR-TTRCC-14004406.

Heel pain-plantar fasciitis: revision 2014

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to nonarthritic heel pain.

Comparison of the responsiveness of the foot health status questionnaire and the Manchester foot pain and disability index in older people

Background

In recent years, several questionnaires have been developed for the assessment of foot health and its impact on quality of life. In order for these tools to be useful outcome measures in clinical trials, their ability to detect change over time (responsiveness) needs to be determined. Therefore, the aim of this study was to assess the responsiveness of two commonly-used questionnaires in older people with foot pain.

Methods

Participants (n = 59; 24 women and 35 men, mean age [SD] 82.3 [7.8] years) allocated to the intervention arm of a randomised controlled trial assessing the effectiveness of extra-depth footwear compared to usual care completed the Foot Health Status Questionnaire (FHSQ) and Manchester Foot Pain and Disability Index (MFPDI) at baseline and 16 weeks. Responsiveness of the FHSQ subscales (pain, function, footwear and general foot health) and MFPDI subscales (pain, functional limitation and concern about appearance) was determined using (i) paired t-tests, (ii) Cohen’s d, (iii) the standardised response mean (SRM), and (iv) the Guyatt index.

Results

Overall, the FHSQ pain subscale exhibited the highest responsiveness, as evidenced by a highly significant paired t-test (p <0.001), Cohen’s d = 0.63 (medium effect size), SRM = 0.50 (medium effect size) and Guyatt index = 1.70 (huge effect size). The next most responsive measure was the FHSQ function subscale, as evidenced by a borderline paired t-test (p = 0.050), Cohen’s d = 0.37 (small effect size), SRM = 0.26 (small effect size) and GI = 1.22 (very large effect size). The FHSQ footwear, FHSQ general foot health and MFPDI pain, functional limitation and concern about appearance subscales demonstrated lower responsiveness, with negligible to medium effect sizes.

Conclusion

The FHSQ pain and function subscales were most responsive to change in older people with foot pain receiving a footwear intervention. These findings provide useful information to guide researchers in selecting appropriate outcome measures for use in future clinical trials of foot disorders.