National profile of foot orthotic provision in the United Kingdom, part 2: podiatrist, orthotist and physiotherapy practices

[Experience with orthopaedic insoles-a cross-sectional study]

BACKGROUND

Orthopaedic insoles (OI) are used to treat a variety of foot problems.

OBJECTIVES

The aim of this cross-sectional study was to investigate the perceptions of the treatment with OI among the manufacturers of the OIs, the orthopaedic technicians (OT).

METHODS

OT from the federal states of Schleswig-Holstein and Lower Saxony in Germany were invited to take part in a survey. The questions included, among others, the number of prescriptions for the production of an OI per month and the materials used. Descriptive statistics, subgroup analyses and a linear regression analysis were performed.

RESULTS

Of the 312 questionnaires distributed, 159 were completed (response rate 51%). Most of the respondents were male (80%). The average age of the participants was 50. On average, OT produced 290 OI per month, with plastic being the most commonly used material (73%). OT with less than 20 years of professional experience are more likely to follow the doctor's instructions when producing OI than OT with more than 20 years of professional experience. The latter are more likely to base their decisions regarding the manufacture and issuing of OI on their own experience.

CONCLUSIONS

The production and issuing process of OI differs among OT. The different professional perspectives of the OT could play a role here, as does the lack of a standardized procedure. The factors listed in this study represent potential starting points for future research projects that could contribute to the development of evidence-based standards.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

Cross sectional survey.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

SETTING

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

PARTICIPANTS

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

PRIMARY AND SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Self-management advice, exercise and foot orthoses for plantar heel pain: the TREADON pilot and feasibility randomised trial

BACKGROUND

Plantar heel pain (PHP) is common and impacts negatively on physical function and quality of life. Initial treatment usually comprises analgesia and self-management advice (SMA), with referral to a physiotherapist or podiatrist recommended only when symptoms persist. Systematic reviews highlight limitations of existing evidence for the effectiveness of exercises and orthoses. The objective of the TREADON pilot and feasibility trial was to inform the design of a future main trial to compare the clinical and cost-effectiveness of self-management advice (SMA), individualised exercises and foot orthoses for PHP.

METHODS

This was a four-arm randomised feasibility and pilot trial with 12-week follow-up. Adults aged ≥ 18 years with PHP were identified from primary care by general practice consultation, retrospective general practice medical record review or a population survey. Participants were randomised to either (i) SMA, (ii) SMA plus individualised exercises (SMA-exercises), (iii) SMA plus prefabricated foot orthoses (SMA-orthoses) or (iv) SMA plus combined individualised exercises and prefabricated foot orthoses (SMA-combined). Feasibility outcomes were recruitment; retention; intervention adherence, credibility and satisfaction; performance of three potential primary outcome measures (pain numeric rating scale (NRS), Foot Function Index-pain subscale (FFI-pain), Manchester Foot Pain and Disability Index-pain subscale (MFPDI-pain)); and parameters for informing the main trial sample size calculation.

RESULTS

Eighty-two participants were recruited. All three identification methods met the target number of participants. Retention at 12 weeks was 67%. All interventions were successfully delivered as per protocol. Adherence (range over 12 weeks 64-100%) and credibility (93%) were highest in the SMA-combined arm. Satisfaction with treatment was higher for the three clinician-supported interventions (SMA 29%, SMA-exercises 72%, SMA-orthoses 71%, SMA-combined 73%). Responsiveness (baseline to 12 weeks) was higher for FFI-pain (standardised response mean 0.96) and pain NRS (1.04) than MFPDI-pain (0.57). Conservative sample size parameter estimates for standard deviation were pain NRS 2.5, FFI-pain 25 and MFPDI-pain 4, and baseline-outcome correlations were 0.5-0.6, 0.4 and < 0.3, respectively.

CONCLUSIONS

We demonstrated the feasibility of conducting a future main randomised clinical trial comparing the clinical and cost-effectiveness of SMA, exercises and/or foot orthoses for PHP.

TRIAL REGISTRATION NUMBER

ISRCTN 12160508 . Prospectively registered 5^th July 2016.

Effectiveness of therapeutic footwear for children: A systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Symptomatic pes planus in children: a synthesis of allied health professional practices

Background

This study sought to explore professional perspectives on the assessment and management of symptomatic pes planus in children.

Methods

Data was collected from three professional groups (podiatrists, physiotherapists, and orthotists) with experience of managing foot problems in children. The survey was undertaken in the United Kingdom via a self-administered, online survey. Data was captured over a four-month period in 2018.

Results

Fifty-five health professionals completed the survey and the results highlighted that assessment techniques varied between professions, with standing tip-toe and joint range of motion being the most common. Treatment options for children were diverse and professionals were adopting different strategies as their first line intervention. All professions used orthoses.

Conclusions

There were inconsistencies in how the health professionals assessed children presenting with foot symptoms, variation in how the condition was managed and differences in outcome measurement. These findings might be explained by the lack of robust evidence and suggests that more effort is needed to harmonise assessment and treatment approaches between professions. Addressing discrepancies in practice could help prioritise professional roles in this area, and better support the management of children with foot pain.

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

OBJECTIVE

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

DESIGN

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

SETTING

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Key concepts in children's footwear research: a scoping review focusing on therapeutic footwear

BACKGROUND

Reports suggest that children with mobility impairment represent a significant proportion of the population living with a disability. Footwear is considered to be the key extrinsic factor affecting children's gait and footwear modifications have been historically postulated to assist with locomotory difficulty. Although therapeutic footwear has been considered within the literature, there is a lack of consistency on terminology and paucity on the overall understanding. A scoping review was performed to chart the key concepts in children's footwear and to establish the range of studies that considered therapeutic footwear.

METHODS

A systematic search of MEDLINE, CINAHL, PubMed, SPORTdiscus, and Scopus electronic databases was performed using MeSH headings and free text terms in relation to children's footwear. All studies that used footwear as an intervention in children aged 9 months to 18 years with the outcome measures including design, fit, and the effects on development and health were included. Studies were charted by textual narrative synthesis into research groupings dependent on the topics discussed and the methods used in the studies.

RESULTS

The search yielded a total of 5006 articles with 287 of these articles meeting the inclusion criteria. Two overarching areas of research were identified; articles that discussed footwear design and those that discussed the effects of footwear. Eight further general groupings were charted and apportioned between the overarching areas and therapeutic footwear was charted into three subgroupings (corrective, accommodative and functional).

CONCLUSION

Children's footwear has become an increasing area of research in the past decade with a shift towards more empirical research, with most of the included articles examining biomechanical and anthropometric aspects. However, children's therapeutic footwear has not shared the same recent impetus with no focused review and limited research exploring its effects. Empirical research in this area is limited and there is ambiguity in the terminology used to describe therapeutic footwear. Based on the findings of this review the authors suggest the term children's therapeutic footwear be used as the standard definition for footwear that is designed specifically with the purpose to support or alleviate mobility impairment in childhood; with subgroupings of corrective, accommodative and functional dependent on the intended therapeutic role.