Unstable Shoe Construction and Reduction of Pain in Osteoarthritis Patients

Optimizing Running Mechanics, Effects of Cadence, Footwear, and Orthoses on Force Distribution: A Quasi-Experimental Study

Background: Running is a popular physical activity known for its health benefits but also for a high incidence of lower-limb injuries. This study examined the effects of three biomechanical interventions-cadence adjustments, footwear modifications, and foot orthoses-on plantar pressure distribution and spatiotemporal running parameters. Methods: A quasi-experimental, repeated-measures design was conducted with 23 healthy recreational runners (mean age 25, mean BMI 22.5) who ran at least twice per week. Five conditions were tested: baseline (C0), increased cadence (C1), orthoses (C2), low-drop footwear (C3), and a combination of these (C4). Data were collected on a Zebris treadmill, focusing on rearfoot contact time, peak forces, and stride length. Results: Increasing cadence (C1) reduced rearfoot impact forces (-81.36 N) and led to a shorter stride (-17 cm). Low-drop footwear (C3) decreased rearfoot contact time (-1.89 ms) and peak force (-72.13 N), while shifting pressure toward the midfoot. Orthoses (C2) effectively redistributed plantar pressures reducing rearfoot peak force (-41.31 N) without changing stride length. The combined intervention (C4) yielded the most pronounced reductions in peak forces across the rearfoot (-183.18 N) and forefoot (-139.09 N) and increased midfoot contact time (+5.07 ms). Conclusions: Increasing cadence and low-drop footwear significantly reduced impact forces, improving running efficiency. Orthoses effectively redistributed plantar pressures, supporting individualized injury prevention strategies. These findings suggest that combining cadence adjustments, footwear modifications, and orthoses could enhance injury prevention and running efficiency for recreational runners.

A Pilot Study on Developed Shoes That Enhance Gait Parameters Without Increasing Muscle Activity

This pilot study investigated the potential of a newly developed shoe design to improve gait parameters without altering muscle activity in healthy women. The shoe design features a V-shaped heel and a high-elasticity midsole, which are intended to enhance stability during heel contact and promote efficient load transfer throughout the gait cycle. Ten study participants underwent a randomized crossover design, wearing developed and general shoes during the trials. Spatiotemporal gait data and muscle activity were measured to assess the impact of the shoe design developed on gait efficiency. Significant improvements in gait speed, step and stride length, and swing time were observed with the developed shoes, indicating improved gait efficiency. Importantly, these improvements were achieved without significant changes in muscle activity, suggesting that the developed shoe design improves gait efficiency without increasing muscle workload. Considering the limitations of the small sample size and the exploratory nature of this pilot study, further research with a larger cohort is necessary to validate these preliminary findings. Trial Registration: Clinical Trial Registry identifier: UMIN000054260.

Cushioned Footwear Effect on Pain and Gait Characteristics of Individuals with Knee Osteoarthritis: A Double-Blinded 3 Month Intervention Study

One of the recommendations for individuals with knee osteoarthritis (OA) is the use of specific footwear, such as sturdy or cushioned shoes. However, the long-term use effects of using cushioned shoes on the pain and spatiotemporal gait parameters in individuals with knee OA are yet to be reported. We therefore aimed to compare the efficacy of cushioned sport footwear versus sham shoes on motor functions, pain and gait characteristics of individuals with knee OA who used the shoes for 3 months. In a double-blinded study, we provided 26 individuals with knee OA with cushioned sport shoes and 12 individuals with knee OA with similar sport shoes without cushioning for 3 months. The gait analysis, the timed up and go (TUG) test and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) were conducted and the pain levels were measured at the baseline, 1 month, and 3 months after the baseline. We found that the cushioned shoes reduce the amount of pain (based on WOMAC) in the affected knee and increase functionality in the research group, but not in the control group. Gait velocity and cadence were increased in both groups. Gait spatiotemporal parameters and their symmetry were unaffected during the intervention. We conclude that the use of cushioned shoes should be recommended to individuals with knee OA for alleviating pain.

A Pilot Study of Muscle Force between Normal Shoes and Bionic Shoes during Men Walking and Running Stance Phase Using Opensim

The original idea for bionic shoes (BSs) involves combining the function of unstable foot conditions and the structure of the human plantar. The purpose of this study was to investigate the differences between the normal shoes (NS) and the BS during the stance phases of walking and running. A total of 15 Chinese males from Ningbo University were recruited for this study (age: 24.3 ± 2.01 years; height: 176.25 ± 7.11 cm, body weight (BW): 75.75 ± 8.35 kg). The participants were asked to perform a walking and running task. Statistical parametric mapping (SPM) analysis was used to investigate any differences between NSs and BSs during the walking and running stance phases. The results demonstrated that there were significant differences found (21.23–28.24%, p = 0.040; 84.47–100%, p = 0.017) in hip extension and flexion between the NS and the BS during the walking stance phase. There were no significant differences found in ankle and moment during the running stance phase. Significant differences were found in the rectus femoris (5.29–6.21%; p = 0.047), tibialis anterior (14.37–16.40%; p = 0.038), and medial gastrocnemius (25.55–46.86%; p < 0.001) between the NS and the BS during the walking stance phase. Significant differences were found in rectus femoris (12.83–13.10%, p = 0.049; 15.89–80.19%, p < 0.001), tibialis anterior (15.85–18.31%, p = 0.039; 21.14–24.71%, p = 0.030), medial gastrocnemius (80.70–90.44%; p = 0.007), and lateral gastrocnemius (11.16–27.93%, p < 0.001; 62.20–65.63%, p = 0.032; 77.56–93.45%, p < 0.001) between the NS and the BS during the running stance phase. These findings indicate that BSs are more efficient for muscle control than unstable shoes and maybe suitable for rehabilitation training.

Ground Reaction Force Differences between Bionic Shoes and Neutral Running Shoes in Recreational Male Runners before and after a 5 km Run

Running-related injuries are common among runners. Recent studies in footwear have shown that designs of shoes can potentially affect sports performance and risk of injury. Bionic shoes combine the functions of barefoot running and foot protection and incorporate traditional unstable structures based on bionic science. The purpose of this study was to investigate ground reaction force (GRF) differences for a 5 km run and how bionic shoes affect GRFs. Sixteen male recreational runners volunteered to participate in this study and finished two 5 km running sessions (a neutral shoe session and a bionic shoe session). Two-way repeated-measures ANOVAs were performed to determine the differences in GRFs. In the analysis of the footwear conditions of runners, bionic shoes showed significant decreases in vertical impulse, peak propulsive force, propulsive impulse, and contact time, while the braking impulse and vertical instantaneous loading rate (VILR) increased significantly compared to the neutral shoes. Main effects for a 5 km run were also observed at vertical GRFs and anterior–posterior GRFs. The increases of peak vertical impact force, vertical average loading rate (VALR), VILR, peak braking force and braking impulse were observed in post-5 km running trials and a reduction in peak propulsive force and propulsive impulse. The interaction effects existed in VILR and contact time. The results suggest that bionic shoes may benefit runners with decreasing injury risk during running. The findings of the present study may help to understand the effects of footwear design during prolonged running, thereby providing valuable information for reducing the risk of running injuries.

An Investigation of Differences in Lower Extremity Biomechanics During Single-Leg Landing From Height Using Bionic Shoes and Normal Shoes

Bionic shoes utilizing an actual foot shape sole structure can alter lower limb’s biomechanics, which may help in the development of specific training or rehabilitation programs. The purpose of this study was to investigate the biomechanical differences in the lower limb during a single-leg landing task using bionic shoes (BS) and normal shoes (NS). Fifteen healthy male subjects participated in this study, sagittal, and frontal plane data were collected during the landing phase (drop landing from 35 cm platform). Our study showed that BS depicted a significantly greater minimum knee flexion angle at initial contact (p = 0.000), a significantly greater minimum (initial contact) hip flexion angle at initial contact (p = 0.009), a significantly smaller sagittal plane total energy dissipation (p = 0.028), a significantly smaller frontal plane total energy dissipation (p = 0.008), a significantly smaller lower limb total energy dissipation (p = 0.017) than NS during the landing phase. SPM analysis revealed that BS depicted a significantly smaller knee joint vertical reaction force during the 13.8–19.8% landing phase (p = 0.01), a significantly smaller anterior tibia shear force during the 14.2–17.5% landing phase (p = 0.024) than NS. BS appears to change lower limb kinematics at initial contact and then readjust the landing strategies for joint work and joint reaction force, thereby reducing the risk of lower limb skeletal muscle injury. BS have great potential for future development and application uses, which may help athletes to reduce lower limb injury risk.

A systematic review of health economic evaluation in orthotics and prosthetics: Part 2-orthotics

BACKGROUND

Health economic evaluations (HEEs) in orthotics are in their infancy. Identification of evidence gaps and method design issues will inform the design of future HEEs that advance knowledge and contributes to policy and investment decisions.

OBJECTIVES

The aim of this systematic review was to critically appraise the existing orthotic/prosthetic health economic evaluation literature and therefore determine evidence gaps, critical method design issues, and the extent to which the literature informs orthotic policy and investment decisions.

STUDY DESIGN

Systematic review.

METHODS

A range of databases were searched using intervention- and HEE-related terms. The Consolidated Health Economic Checklist-Extended and the Checklist for Health Economic Evaluation Reporting Standards were used to identify issues with method design and reporting.

RESULTS

Nine orthotic HEEs were narrowly focused on the cost-effectiveness of low-cost orthotic devices (eg, ankle orthoses for ankle sprains). Method design (eg, cost identification and valuation) and reporting issues (eg, lack of detail about the study population) limited the extent to which this literature can inform policy and investment decisions.

CONCLUSIONS

HEEs comparing a wider variety of interventions are required, particularly for commonly used orthoses (eg, ankle-foot orthoses) and clinical presentations (eg, post-stroke). There are opportunities to strengthen future orthotic HEEs by adopting method design features (eg, microcosting and sensitivity analyses) as recommended by HEE appraisal and reporting tools.

Foot characteristics and mechanics in individuals with knee osteoarthritis: systematic review and meta-analysis

Background

Foot characteristics and mechanics are hypothesized to affect aetiology of several lower extremity musculoskeletal conditions, including knee osteoarthritis (KOA). The purpose of this systematic review was to identify the foot characteristics and mechanics of individuals with KOA.

Methods

Five databases were searched to identify relevant studies on foot characteristics and mechanics in people with KOA. Meta-analyses were performed where common measures were found across included studies. Included studies were evaluated for data reporting quality using the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist.

Results

Thirty-nine studies were included in this systematic review. Two studies reported participants with KOA had statistically significantly (P < 0.05) more pronated foot postures than those without. Meta-analyses for foot progression angle (FPA) and peak rearfoot eversion angle found no difference between those with and without KOA (FPA mean difference:-1.50 [95% confidence interval − 4.20-1.21]; peak rearfoot eversion mean difference: 0.71 [1.55–2.97]).

Conclusion

A more pronated foot posture was noticed in those with KOA. However, it was not possible to establish a relationship between other foot characteristics or mechanics in people with KOA due to heterogeneity between the included study and limited number of studies with similar measurements. There is need for identifying common measurement techniques and reporting metrics when studying the foot in those with KOA.

The effect of the combination of whole body vibration and shoe with an unstable surface in chronic ankle instability treatment: a randomized clinical trial

Background

Chronic ankle instability (CAI) is a common condition following an ankle sprain. This study investigated the effects of whole body vibration (WBV) and shoe with an unstable surface training on balance, functional performance, strength, joint position sense in people with CAI.

Method

Thirty- four peoples with unilateral CAI were randomly assigned to three groups: WBV group, WBV with shoe with an unstable surface (WBV-S), and no treatment control group (CON). The WBV group received 4 weeks progressive WBV training and the WBV-S group received progressive WBV training with shoe with an unstable surface. Modified star excursion balance test (mSEBT)reach distance, Hop-Test, muscle strength, and joint position sense were measured at baseline and after the 4 weeks; Moreover, the mSEBT and Hop-Test were reassessed again 2 weeks post intervention.

Results

The result showed a significant group-by-time interaction for anterior and posterolateral directions of mSEBT. The reach distance of these directions at post-intervention and follow-up increased significantly compare to pre-intervention in the WBV and WBV-S groups but not significantly change in the CON group. The Hop test in the WBV-S group was significantly more at post-intervention and follow-up compared to pre-intervention. However, no significant changes were observed in WBV and CON groups. No significant changes were observed for mSEBT posteromedial direction, muscles strength, and joint position sense errors.

Conclusion

The 4 weeks WBV and WBV-S interventions could improve balance in peoples with CAI. Improvement in Hop test was only observed in the WBV-S group suggesting the added value of combining WBV and shoe with an unstable surface as an effective therapy compared to WBV training alone. The use of WBV and WBV-S were not associated with significant changes in strength and joint position sense variables over a four-week period.

Trial registration

This work registered in the Iranian Registry of Clinical Trials (IRCT20151118025105N4).

Prolonged Running Using Bionic Footwear Influences Lower Limb Biomechanics

The running biomechanics of unstable shoes have been well investigated, however, little is known about how traditional neutral shoes in combination with unstable design elements and scientifically (bionic) designed shoes influence prolonged running biomechanics. The purpose of this study was to investigate biomechanical changes for a typical 5 km run and how footwear technology may affect outcomes. Sixteen healthy male recreational heel strike runners participated in this study, and completed two prolonged running sessions (neutral shoe session and bionic shoe session), with 7 to 10 days interval between sessions. A two-way repeated-measures analysis of variance (ANOVA, shoe × time) was conducted to determine any differences in joint biomechanics. Main effects for shoe type were observed at the ankle, knee and hip joints during the stance phase. In particular, decreased range of motion (ROM) was observed using the bionic shoes for all three joints, and the joint moments also had significant changes except for the frontal plane of the hip. Main effects for time were also observed at the ankle, knee and hip joints. The ROM of the sagittal plane in the knee and hip decreased post-5 km running. The reduction of ankle dorsiflexion, hip flexion, hip adduction and hip internal rotation angles were observed post-5 km running, as well as the increase of ankle eversion and external rotation, knee adduction and internal rotation angles. The kinetics also exhibited significant differences between pre-5 km running and post-5 km running. The interaction effects only existed in the ROM of the hip sagittal plane, hip adduction angle and hip internal rotation angle. The results suggested that bionic shoes could be beneficial for strengthening muscle control, enhancing postural stability and proprioceptive ability. Footwear personalization could be a solution that benefits runners, reduces injury risk and improves running performance.

The effectiveness of foot orthoses in the treatment of medial knee osteoarthritis: A systematic review

BACKGROUND

Knee osteoarthritis is a disease of the joint causing decreased function and pain. Currently, treatments range from medication to surgery, with the use of different insoles and footwear recommended. These methods are effective by either correcting the position of the knee or providing shock absorption. However, there is little understanding of the effective characteristics of these devices.

RESEARCH QUESTION

This paper aims to investigate this question and provide future areas of research to help better define treatment guidelines. Foot orthoses are an example of non-pharmacological conservative treatments mentioned in National Institute for Health and Care Excellence (NICE) guidelines to treat knee osteoarthritis (OA). These include lateral wedge insoles (LWI), developed with the intention of load reduction of the knee. Different footwear has also been shown to affect pain, biomechanical and functional outcomes in knee OA patients.

METHODS

To address what features of LWIs and footwear make them effective in the treatment of knee OA, scientific databases were used to search for papers on this topic and then selected to be included based on pre-defined criteria. Data were extracted and analysed from these studies to provide a basis for possible areas for future development of these foot orthoses, and research required to improve clinical treatment guidelines. Databases used were PubMed, Scopus and Web of Science.

RESULTS AND SIGNIFICANCE

Thirty-four out of 226 papers were included after application of inclusion and exclusion criteria. Regarding LWIs, the characteristics showing the most beneficial effect on either biomechanical, functional or pain outcomes were customisation, full-length, 5° elevation, shock absorption and arch support. For footwear, barefoot mimicking soles produced the most favourable biomechanics. Results also showed that insoles work in correcting the position of the knee, but it may or may not affect patients' pain and function.

The effect of shoe and floor characteristics on walking kinematics

It is common sense that walking on sand poses challenges to postural control. However, there are no studies quantifying the kinematics of sand walking compared to other types of postural perturbations such as unstable shoes. The aim of the study was to investigate differences in walking kinematics during walking on solid ground, in unstable shoes and on unstable surfaces. Nineteen healthy young adults (23.5 ± 1.5 years) performed three different walking tasks: 1) walking at preferred speed while wearing regular shoes; 2) Walking at preferred speed wearing Masai Barefoot Technology shoes and 3) barefoot walking at preferred speed on a large sand grave. Full-body kinematics were recorded during all conditions using an inertial motion capture system. Basic gait parameters (walking speed, stride length and duration), relative vertical center-of-mass position (rvCOM), and ankle, knee and hip joint angles in the sagittal plane were compared across the tasks through statistical parametric mapping over the course of full walking cycles. Participants presented similar walking speed, as well as stride length and duration across different conditions (p > 0.05). However, walking on sand reduced the rvCOM (p < 0.05), while also requiring greater ankle plantarflexion during stance phase (p < 0.05), as well as greater knee and hip flexion during leg swing and initial contact when compared to the other conditions (p < 0.05). It was concluded that walking on sand substantially changes walking kinematics, and may cause greater postural instability than unstable shoes. Therefore, walking on sand can be an alternative to improve postural control in patients undergoing walking rehabilitation.

The effect of unstable shoe designs on the variability of gait measures

BACKGROUND

Unstable footwear designs are popular as training devices to strengthen human neuromuscular control, and many studies have evaluated their effect on gait parameters in comparison to conventional footwear designs. However, there is minimal research on variability of gait measures during walking with unstable shoes. Therefore, the study objective was to compare variability of gait measures between stable and unstable shoe configurations, in conjunction with kinematic and kinetic changes.

METHODS

Fifteen healthy male subjects walked in both a stable and unstable footwear device configuration while full-body gait kinematic and kinetic data was collected. Averages and standard deviations of gait trials were compared between the two configurations at different stages of each step.

RESULTS

Comparison of gait variability between both footwear configurations revealed that variability of frontal-plane foot center of pressure offset, transverse-plane ankle moment, and frontal-plane shoulder angle decreased significantly while walking in the unstable configuration, while transverse-plane spine angle variability increased. No changes in variability of gait measures at the knee, hip, or pelvis were observed. Kinematic and kinetic changes were observed throughout the whole body with the unstable shoe.

CONCLUSION

Our findings suggest that the unstable device used in the study may reduce gait variability at the two extremes of the kinematic chain (i.e., foot, ankle, and shoulders), but increase variability of spine rotation angle. This may suggest a compensatory mechanism to maintain both stability and adaptability, and may have potential clinical implications for gait retraining and enhancing dynamic gait stability and joint stability, pending further investigation.

Effects of lateral-offset sole shoes on knee adduction moment in women with medial compartment knee osteoarthritis

This study aimed to determine the impact of wearing a lateral-offset sole shoe (LOSS) on knee adduction moment (KAM) in patients with medial knee osteoarthritis (OA). From December 2012 to November 2016, patients with medial knee OA were recruited. Ninety-three knees (50 left, 43 right) of 93 female patients were analyzed. The first peak KAMs were measured with patients (i) walking barefoot; (ii) walking in conventional shoes; and (iii) walking in LOSSs. The patients had grade 1 (n = 19), grade 2 (n = 49), grade 3 (n = 20), and grade 4 (n = 5) knee OA. First peak KAMs differed significantly in all three conditions (p = 0.031). In the post hoc analysis, first peak KAMs were significantly lower during LOSS walking than during conventional shoe walking (p = 0.001), but there were no differences in peak KAMs between barefoot and LOSS walking (p = 0.784). In the subgroup analysis, patients with grades 2 and 3 OA showed significantly lower first peak KAMs during LOSS walking than during conventional shoe walking (p = 0.029 and p = 0.011, respectively). Both the peak eversion ankle angle and moment of barefoot walking showed a significant increase compared with LOSS and conventional shoe walking, while there was no significant difference between LOSS and conventional shoe walking (p = 0.612 and p = 0.197, respectively). Our results suggest that LOSS wearing caused significant KAM reductions compared with conventional shoe wearing. Since LOSS wearing does not cause changes in the peak eversion ankle angle and moment during the load response, it may be an effective method to reduce the KAM in women with knee OA. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1694-1700, 2018.

Unstable rocker shoes promote recovery from marathon-induced muscle damage in novice runners

We recently reported that wearing unstable rocker shoes (Masai Barefoot Technology: MBT) may enhance recovery from marathon race-induced fatigue. However, this earlier study only utilized a questionnaire. In this study, we evaluated MBT utilizing objective physiological measures of recovery from marathon-induced muscle damages. Twenty-five university student novice runners were divided into two groups. After running a full marathon, one group wore MBT shoes (MBT group), and the control group (CON) wore ordinary shoes daily for 1 week following the race. We measured maximal isometric joint torque, muscle hardness (real time tissue elastography of the strain ratio) in the lower limb muscles before, immediately after, and 1, 3, and 8 days following the marathon. We calculated the magnitude of recovery by observing the difference in each value between the first measurement and the latter measurements. Results showed that isometric torques in knee flexion recovered at the first day after the race in the MBT group while it did not recover even at the eighth day in the CON group. Muscle hardness in the gastrocnemius and vastus lateralis showed enhanced recovery in the MBT group in comparison with the CON group. Also for muscle hardness in the tibialis anterior and biceps femoris, the timing of recovery was delayed in the CON group. In conclusion, wearing MBT shoes enhanced recovery in lower leg and thigh muscles from muscle damage induced by marathon running.

Effects of unstable footwear on gait characteristic: A systematic review

BACKGROUND

Over the last three decades, several designs of unstable footwear have been developed in the forms of shoes, sandals and boots. There are marketing claims related to the positive effects of these shoes on the training of lower limb muscles and improving gait. Many studies have been performed on the effects of unstable footwear on muscle activity, balance, posture, energy expenditure, lower extremity disorders, and biomechanical changes. The analysis of the kinetics and kinematics characteristics of gait would provide objective representation of body movement.

OBJECTIVE

To systematically review available evidence on the use of unstable footwear on kinetic and kinematic parameters to make specific recommendation for practice and future studies.

METHOD

A computer-based search was undertaken through PubMed, Cochrane Library, Embase, PEDro, Web of Science and Google Scholar from 2005 to 2015. The included studies were appraised using McMaster Critical Review Form for Quantitative Studies.

RESULT

Ten studies (quasi-experimental design) were included.

CONCLUSION

Considering kinetic and kinematic interaction of variables in the included studies revealed that confounding factors may have high impact on biomechanical findings of unstable footwear. Then, more homogeneous studies, considering these factors, should be implemented in future studies to inform the best clinical practice.

Acupuncture for chronic pain and depression in primary care: a programme of research

Background

There has been an increase in the utilisation of acupuncture in recent years, yet the evidence base is insufficiently well established to be certain about its clinical effectiveness and cost-effectiveness. Addressing the questions related to the evidence base will reduce uncertainty and help policy- and decision-makers with regard to whether or not wider access is appropriate and provides value for money.

Aim

Our aim was to establish the most reliable evidence on the clinical effectiveness and cost-effectiveness of acupuncture for chronic pain by drawing on relevant evidence, including recent high-quality trials, and to develop fresh evidence on acupuncture for depression. To extend the evidence base we synthesised the results of published trials using robust systematic review methodology and conducted a randomised controlled trial (RCT) of acupuncture for depression.

Methods and results

We synthesised the evidence from high-quality trials of acupuncture for chronic pain, consisting of musculoskeletal pain related to the neck and low back, osteoarthritis of the knee, and headache and migraine, involving nearly 18,000 patients. In an individual patient data (IPD) pairwise meta-analysis, acupuncture was significantly better than both sham acupuncture (p < 0.001) and usual care (p < 0.001) for all conditions. Using network meta-analyses, we compared acupuncture with other physical therapies for osteoarthritis of the knee. In both an analysis of all available evidence and an analysis of a subset of better-quality trials, using aggregate-level data, we found acupuncture to be one of the more effective therapies. We developed new Bayesian methods for analysing multiple individual patient-level data sets to evaluate heterogeneous continuous outcomes. An accompanying cost-effectiveness analysis found transcutaneous electrical nerve stimulation (TENS) to be cost-effective for osteoarthritis at a threshold of £20,000 per quality-adjusted life-year when all trials were synthesised. When the analysis was restricted to trials of higher quality with adequate allocation concealment, acupuncture was cost-effective. In a RCT of acupuncture or counselling compared with usual care for depression, in which half the patients were also experiencing comorbid pain, we found acupuncture and counselling to be clinically effective and acupuncture to be cost-effective. For patients in whom acupuncture is inappropriate or unavailable, counselling is cost-effective.

Conclusion

We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed. When all trials are analysed, TENS is cost-effective. Promising clinical and economic evidence on acupuncture for depression needs to be extended to other contexts and settings. For the conditions we have investigated, the drawing together of evidence on acupuncture from this programme of research has substantially reduced levels of uncertainty. We have identified directions for further research. Our research also provides a valuable basis for considering the potential role of acupuncture as a referral option in health care and enabling providers and policy-makers to make decisions based on robust sources of evidence.

Trial registration

Current Controlled Trials ISRCTN63787732.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Do rocker-sole shoes influence postural stability in chronic low back pain? A randomised trial

Background

People with chronic low back pain (CLBP) demonstrate greater postural instability compared with asymptomatic individuals. Rocker-sole shoes are inherently unstable and may serve as an effective balance training device. This study hypothesised that wearing rocker-sole shoes would result in long-term improvement in barefoot postural stability in people with CLBP.

Methods

20 participants with CLBP were randomised to wear rocker-sole or flat-sole shoes for a minimum of 2 hours each day. Participants were assessed barefoot and shod, over three 40 s trials, under 4 posture challenging standing conditions. The primary outcome was postural stability assessed by root mean squared error of centre of pressure (CoP) displacement (CoP_{RMSE AP}) and mean CoP velocity (CoP_VELAP), both in the anteroposterior direction, using force plates. Participants' were assessed without knowledge of group allocation at baseline, 6 weeks and 6 months (main outcome point). Analyses were by intention-to-treat.

Results

At 6 months, data from 11 of 13 (84.6%) of the rocker-sole and 5 of 7 (71.4%) of the flat-sole group were available for analysis. At baseline, there was a mean increase in CoP_{RMSE AP} (6.41 (2.97) mm, p<0.01) and CoP_VELAP (4.10 (2.97) mm, p<0.01) in the rocker-sole group when shod compared with barefoot; there was no difference in the flat-sole group. There were no within-group or between-group differences in change in CoP parameters at any time point compared with baseline (1) for any barefoot standing condition (2) when assessed shod eyes-open on firm ground.

Conclusions

Although wearing rocker-sole shoes results in greater postural instability than flat-sole shoes, long-term use of rocker-sole shoes did not appear to influence postural stability in people with CLBP.

Influence of different safety shoes on gait and plantar pressure: a standardized examination of workers in the automotive industry

Objective:

Working conditions, such as walking and standing on hard surfaces, can increase the development of musculoskeletal complaints. At the interface between flooring and musculoskeletal system, safety shoes may play an important role in the well-being of employees. The aim of this study was to evaluate the effects of different safety shoes on gait and plantar pressure distributions on industrial flooring.

Methods:

Twenty automotive workers were individually fitted out with three different pairs of safety shoes ( "normal" shoes, cushioned shoes, and midfoot bearing shoes). They walked at a given speed of 1.5 m/s. The CUELA measuring system and shoe insoles were used for gait analysis and plantar pressure measurements, respectively. Statistical analysis was conducted by ANOVA analysis for repeated measures.

Results:

Walking with cushioned safety shoes or a midfoot bearing safety shoe led to a significant decrease of the average trunk inclination (p<0.005). Furthermore, the average hip flexion angle decreased for cushioned shoes as well as midfoot bearing shoes (p<0.002). The range of motion of the knee joint increased for cushioned shoes. As expected, plantar pressure distributions varied significantly between cushioned or midfoot bearing shoes and shoes without ergonomic components.

Conclusion:

The overall function of safety shoes is the avoidance of injury in case of an industrial accident, but in addition, safety shoes could be a long-term preventive instrument for maintaining health of the employees' musculoskeletal system, as they are able to affect gait parameters. Further research needs to focus on safety shoes in working situations.

The effect of Masai Barefoot Technology (MBT) footwear on lower limb biomechanics: A systematic review

This systematic review evaluated the available evidence for the effects of Masai Barefoot Technology (MBT) footwear on lower limb biomechanics during gait. Electronic databases (MEDLINE, EMBASE, CINAHL, SPORTDiscus, and PubMed) were searched in January 2015. Methodological quality of included studies was evaluated using the Quality Index. Standardised mean differences and 95% confidence intervals were calculated, and meta-analysis was conducted where possible. 17 studies satisfied the inclusion criteria; 16 cross-sectional studies and one randomised control trial (RCT). Quality Index scores ranged from 7 to 12 (out of 15). All 17 studies investigated walking gait only. Evidence showed that MBT footwear caused asymptomatic individuals to walk with a shorter stride length, reduced peak hip flexion, increased peak knee extension, and reduced hip and knee range of motion throughout gait. All kinematic effects occurred in the sagittal plane. There was a trend towards a decrease in internal and external joint moments and power, except for the foot, where increases in force were observed. There were only a small number of changes to lower limb muscle amplitude and timing. No statistically significant effects were observed in symptomatic individuals with knee osteoarthritis or following total knee replacement, but there was an increase in cadence and a decrease in step length in individuals following tibiotalar arthrodesis. These findings suggest that MBT footwear does change lower limb biomechanics in both asymptomatic and symptomatic individuals during gait. However, further clinical trials need to be undertaken to determine whether these changes are therapeutically beneficial.

Therapeutic modalities and postural balance of patients with knee osteoarthritis: systematic review

AbstractObjective The objective of this review was to evaluate the evidence of the influence of therapeutic modalities on postural balance in patients with knee osteoarthritis (OA).Methods A search for published papers on therapeutic modalities was conducted using the Pubmed, Medline, Lilacs and SciELO databases. The keywords “knee” and “balance” in combination with “osteoarthritis” were used as the search strategy. Randomized controlled clinical trials published in the last 10 years in either English or Portuguese were selected. The PEDro scale was applied to assess the quality of the selected clinical trials.Results A total of 46 studies of patients with knee OA were found, of which seven were analyzed in full and 39 were excluded because they did not meet the inclusion criteria. Of the seven studies reviewed, six were considered to have a high methodological quality on the PEDro scale. Several therapeutic modalities were found (physical exercise, hydrotherapy, electrotherapy and manual therapy), and postural balance improved in only three studies.Conclusion The studies included in this systematic review had a high methodological quality, so it can be concluded that the therapeutic modalities used in those studies improved postural balance in patients with knee OA.

Biomechanical and neural changes evaluation induced by prolonged use of non-stable footwear: a systematic review

The aim of this review is to collect and discuss the current best evidence published in literature about the effect of the Masai Barefoot Technology(MBT) shoes on gait and muscle activation and try to draw conclusions on the possible benefits. We searched Medline, CINAHL, Embase and the Cochrane Central Registry of Controlled Trials. The reference lists of the previously selected articles were then examined by hand. Only studies comparing biomechanical and clinical outcomes were selected. Review, anatomical studies, letter to editor and instructional course were excluded. Finally, all the resulting articles were reviewed and discussed by all the authors to further confirm their suitability for this review: in the end, 22 articles were included. A total of 532 patients presenting a mean age of 34.3 years were studied. All patients evaluated were healthy or amateur sports except in two studies where only obese subjects and knee osteoarthritis patients were involved. Seven studies evaluated only male subjects, whereas four studies evaluated only female. Twelve of twenty-two studies performed electromyographic analyses. Weight was reported in 19 studies, whereas body mass index were reported only in a five studies. All studies reported kinematic analysis of shoe effects and compared the relationship between muscle recruitment and electromyographic activity. Unstable footwears were shown to immediately alter the stability in gait during daily-life activities. The center of body pressure is moved posteriorly with a consequent posterior displacement of the upper part of body in order to regain an appropriate body balance, and these postural changes are associated with an overall increase in the activity of lumbar erector spine muscles, as well as certain lower limb muscles. Current literature provides enough cues to conclude for a beneficial role of MBT shoes in the postural and proprioceptive recovery, but from the same literature cannot be drown clear and appropriate guidance to determine more in detail their indication for specific pathological conditions or for particular phases of the musculoskeletal recovery process.

Does wearing unstable shoes reduce low back pain and disability in nurses? A randomized controlled pilot study

OBJECTIVE

To evaluate if wearing unstable shoes reduces low back pain and disability in nurses.

DESIGN

A randomized controlled trial.

SETTING

Hospitals and homecare.

SUBJECTS

A total of 20 matched female registered nurses with low back pain. The mean (standard deviation) age was 31 years (5) for the control and 34 years (6) for the intervention group; height was 161 cm (5) and 165 cm (7), respectively.

INTERVENTIONS

The intervention group received unstable shoes at Week 2 to wear for at least 36 h/week for a month.

MAIN MEASURES

The Oswestry Low Back Pain Disability Questionnaire and a visual analogue pain scale.

RESULTS

The mean (standard deviation) pain level was 6 (1) at baseline vs. 6 (2) at Week 6 for the control group, and 5 (1) vs. 1 (1) for the intervention group. The mean (standard deviation) disability level was 31% (9) at baseline vs. 28% (7) at Week 6 for the control, and 27% (12) vs. 13% (5) for the intervention group. There were no significant changes over time on pain or disability levels for the control group. The intervention group reported lower levels of pain on Weeks 4 (mean difference ⩾-1.4, p ⩽ 0.009) and 6 (mean difference ⩾-3.1, p < 0.001). Disability levels were also lower on Weeks 4 (mean difference = -4.5%, p NS) and 6 (mean difference = -14.1%, p = 0.020).

CONCLUSIONS

Wearing unstable shoes reduced low back pain and disability in nurses and might be helpful as part of the back pain rehabilitation process.

Post-marathon wearing of Masai Barefoot Technology shoes facilitates recovery from race-induced fatigue: an evaluation utilizing a visual analog scale

Purpose

To investigate the potential benefit of post-race wearing of unstable shoes (Masai Barefoot Technology [MBT]) on recovery from marathon race–induced fatigue.

Patients and methods

Forty-five runners who participated in a full marathon race were divided into three groups: 1) MBT shoes, 2) trail running shoes, and 3) control (CON). Participants ran a full marathon with their own running shoes, and then put on the assigned shoes immediately after the race. They continued to wear the assigned shoes for the ensuing 3 days. The CON group wore their usual shoes. Estimates of post-race fatigue were made by the participants on questionnaires that utilized a visual analog scale. Estimates were made just after the race, as well as for the next 3 days.

Results

The subjective fatigue of the MBT group was lower than that of the CON (P<0.05) or trail running shoe groups (P<0.05) on day 3.

Conclusion

MBT shoe intervention can promote recovery from the fatigue induced by running a full marathon.

Self-reported adult footwear and the risks of lower limb osteoarthritis: the GOAL case control study

Background

Biomechanical factors may play a role in osteoarthritis (OA) development and progression. Previous biomechanical studies have indicated that types of footwear may modulate forces across the knee joint, and high heeled womens’ shoes in particular are hypothesised to be detrimental to lower limb joint health. This analysis of data from a case control study investigated persistent users of different adult footwear for risks of knee and hip OA. Our underlying hypotheses were that high heeled, narrow heeled, and hard soled shoe types were putative risk factors for lower limb OA.

Methods

Data on footwear were initially obtained from participants during the Genetics of Osteoarthritis and Lifestyle (GOAL) hospital-based, case control study using standardised interview-delivered questionnaires. An additional questionnaire was later sent to GOAL study participants to verify findings and to further investigate specific shoe use per decade of life. Persistent users of footwear types (high or narrow heel; sole thickness or hardness) were identified from early adulthood. Participants were grouped into single sex knee OA, hip OA or control groups. Adjusted odds ratios (aOR) and 95% confidence interval (CI) were calculated.

Results

Univariate analysis of persistent users of women’s high heeled and narrow heeled shoes during early adulthood showed negative associations with knee OA and hip OA. After logistic regression, persistent narrow heel users were associated with less risk of OA (knee OA aOR 0.59, 95% CI 0.35 – 1.00 and hip aOR: 0.50, 95% CI 0.30 – 0.85), and other analyses were not statistically significant. Further analysis suggested that women with hip OA may have stopped wearing high and narrow heeled footwear to attenuate hip pain in early adulthood. Consistent associations between shoe soles and OA were not found.

Conclusions

In general, persistent users of high and narrow heeled shoes during early adulthood had a negative association with knee or hip OA. This does not necessarily imply a causal relationship, as changing footwear during early adulthood to modulate index joint pain may provide a possible explanation. Despite the findings of previous biomechanical studies of high heels, we did not find a positive association between women’s shoes and lower limb osteoarthritis.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-308) contains supplementary material, which is available to authorized users.

Does increasing step width alter knee biomechanics in medial compartment knee osteoarthritis patients during stair descent?

BACKGROUND

Research shows that one of the first complaints from knee osteoarthritis (OA) patients is difficulty in stair ambulation due to knee pain. Increased step width (SW) has been shown to reduce first and second peak internal knee abduction moments, a surrogate variable for medial compartment knee joint loading, during stair descent in healthy older adults. This study investigates the effects of increased step width (SW) on knee biomechanics and knee pain in medial compartment knee OA patients during stair descent.

METHODS

Thirteen medial compartment knee OA patients were recruited for the study. A motion analysis system was used to obtain three-dimensional joint kinematics. An instrumented staircase was used to collect ground reaction forces (GRF). Participants performed stair descent trials at their self-selected speed using preferred, wide, and wider SW. Participants rated their knee pain levels after each SW condition.

RESULTS

Increased SW had no effect on peak knee abduction moments and knee pain. Patients reported low levels of knee pain during all stair descent trials. The 2nd peak knee adduction angle and frontal plane GRF at time of 2nd peak abduction moment were reduced with increasing SW.

CONCLUSIONS

The findings suggest that increases in SW may not influence knee loads in medial compartment knee OA patients afflicted with low levels of knee pain during stair descent.

Limits of Stability and Adaptation to Wearing Rocker Bottom Shoes

BACKGROUND

Stability and balance are fundamental during static and dynamic activities. The effects of wearing rocker bottom sole (RBS) shoes on the limits of stability (LOS) and adaptation to wearing RBS shoes need to be investigated. The objectives of this study were to evaluate the LOS when wearing RBS shoes, and to evaluate if people improve their stability while wearing RBS shoes over time.

METHODS

Eleven female subjects with no lower extremity impairments participated in the study. The LOS were tested at baseline and weeks 3 and 6 using a Neurocom SMART EquiTest equipment. Center of pressure (CoP) was determined using force plates, and the center of gravity (CoG) position was estimated from the CoP measures and subjects' anthropometry. Subjects performed a series of tasks that involved leaning in different directions so as to move the vertical projection of their CoG. End-point excursions of the CoG floor projection were calculated as a percentage of the distance between the starting position and the target. Considering the body as an inverted pendulum, we recorded the average angular velocity of the inverted pendulum during the movements and quantified directional control as a percentage of movement toward versus away from the target. Shoe types were compared using paired t tests, and sessions were compared using repeated measures ANOVA.

RESULTS

The angular velocities of the inverted pendulum (ie, CoG velocity) were not significantly different between shoe conditions in the front and back directions at baseline (4 ± 3 with RBS vs 5 ± 2 deg/sec with regular shoes, and 4 ± 1 vs 6 ± 4 deg/sec). Front directional control of the CoG was significantly worse with RBS shoes at weeks 3 and 6 ( P < .015). Front end-point excursions were also lower with RBS shoes both at baseline and week 6 ( P < .014). There were no significant changes over time.

CONCLUSION

The findings indicate that the LOS were negatively affected by wearing RBS shoes and that people do not improve their stability while wearing these shoes even after a 6-week period of use.

CLINICAL RELEVANCE

This study shows that wearing RBS shoes increase instability and the instability remains even after wearing these shoes for six weeks.

Effect of rocker-soled shoes on parameters of knee joint load in knee osteoarthritis

PURPOSE

This study evaluated the immediate effects of rocker-soled shoes on parameters of the knee adduction moment (KAM) and pain in individuals with knee osteoarthritis (OA).

METHODS

Three-dimensional gait analysis was performed on 30 individuals (mean (SD): age, 61 (7) yr; 15 (50%) male) with radiographic and symptomatic knee OA under three walking conditions in a randomized order: i) wearing rocker-soled shoes (Skechers Shape-ups), ii) wearing non-rocker-soled shoes (ASICS walking shoes), and iii) barefoot. Peak KAM and KAM angular impulse were measured as primary indicators of knee load distribution. Secondary measures included the knee flexion moment (KFM) and knee pain during walking.

RESULTS

Peak KAM was significantly lower when wearing the rocker-soled shoes compared with that when wearing the non-rocker-soled shoes (mean difference (95% confidence interval), -0.27 (-0.42 to -0.12) N·m/BW × Ht%; P < 0.001). Post hoc tests revealed no significant difference in KAM impulse between rocker-soled and non-rocker-soled shoe conditions (P = 0.13). Both peak KAM and KAM impulse were significantly higher during both shoe conditions compared with those during the barefoot condition (P < 0.001). There were no significant differences in KFM (P = 0.36) or knee pain (P = 0.89) between conditions.

CONCLUSIONS

Rocker-soled shoes significantly reduced peak KAM when compared with non-rocker-soled shoes, without a concomitant change in KFM, and thus may potentially reduce medial knee joint loading. However, KAM parameters in the rocker-soled shoes remained significantly higher than those during barefoot walking. Wearing rocker-soled shoes did not have a significant immediate effect on walking pain. Further research is required to evaluate whether rocker-soled shoes can influence symptoms and progression of knee OA with prolonged wear.

Immediate effect of Masai Barefoot Technology shoes on knee joint moments in women with knee osteoarthritis

Footwear modification can beneficially alter knee loading in patients with knee osteoarthritis. This study evaluated the effect of Masai Barefoot Technology shoes on reductions in external knee moments in patients with knee osteoarthritis. Three-dimensional motion analysis was used to examine the effect of Masai Barefoot Technology versus control shoes on the knee adduction and flexion moments in 17 women (mean age, 63.6 years) with radiographically confirmed knee osteoarthritis. The lateral and anterior trunk lean values, knee flexion and adduction angles, and ground reaction force were also evaluated. The influence of the original walking pattern on the changes in knee moments with Masai Barefoot Technology shoes was evaluated. The knee flexion moment in early stance was significantly reduced while walking with the Masai Barefoot Technology shoes (0.25±0.14Nm/kgm) as compared with walking with control shoes (0.30±0.19 Nm/kgm); whereas the knee adduction moment showed no changes. Masai Barefoot Technology shoes did not increase compensatory lateral and anterior trunk lean. The degree of knee flexion moment in the original walking pattern with control shoes was correlated directly with its reduction when wearing Masai Barefoot Technology shoes by multiple linear regression analysis (adjusted R2=0.44, P<0.01). Masai Barefoot Technology shoes reduced the knee flexion moment during walking without increasing the compensatory trunk lean and may therefore reduce external knee loading in women with knee osteoarthritis.

Rocker-sole footwear versus prefabricated foot orthoses for the treatment of pain associated with first metatarsophalangeal joint osteoarthritis: study protocol for a randomised trial

BACKGROUND

Osteoarthritis affecting the first metatarsophalangeal joint of the foot is a common condition which results in pain, stiffness and impaired ambulation. Footwear modifications and foot orthoses are widely used in clinical practice to treat this condition, but their effectiveness has not been rigorously evaluated. This article describes the design of a randomised trial comparing the effectiveness of rocker-sole footwear and individualised prefabricated foot orthoses in reducing pain associated with first metatarsophalangeal joint osteoarthritis.

METHODS

Eighty people with first metatarsophalangeal joint osteoarthritis will be randomly allocated to receive either a pair of rocker-sole shoes (MBT® Matwa, Masai Barefoot Technology, Switzerland) or a pair of individualised, prefabricated foot orthoses (Vasyli Customs, Vasyli Medical™, Queensland, Australia). At baseline, the biomechanical effects of the interventions will be examined using a wireless wearable sensor motion analysis system (LEGSys™, BioSensics, Boston, MA, USA) and an in-shoe plantar pressure system (Pedar®, Novel GmbH, Munich, Germany). The primary outcome measure will be the pain subscale of the Foot Health Status Questionnaire (FHSQ), measured at baseline and 4, 8 and 12 weeks. Secondary outcome measures will include the function, footwear and general foot health subscales of the FHSQ, severity of pain and stiffness at the first metatarsophalangeal joint (measured using 100 mm visual analog scales), global change in symptoms (using a 15-point Likert scale), health status (using the Short-Form-12® Version 2.0 questionnaire), use of rescue medication and co-interventions to relieve pain, the frequency and type of 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.

DISCUSSION

This study is the first randomised trial to compare the effectiveness of rocker-sole footwear and individualised prefabricated foot orthoses in reducing pain associated with osteoarthritis of the first metatarsophalangeal joint, and only the third randomised trial ever conducted for this condition. The study has been pragmatically designed to ensure that the findings can be implemented into clinical practice if the interventions are found to be effective, and the baseline biomechanical analysis will provide useful insights into their mechanism of action.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12613001245785.

Gait biomechanics of a second generation unstable shoe

The recent popularity of unstable shoes has sparked much interest in the efficacy of the shoe design. Anecdotal evidence suggests that earlier designs appear bulky and less aesthetically appealing for everyday use. The purpose of this study was to examine effects of a second generation unstable shoe on center of pressure (COP), ground reaction force (GRF), kinematics, and kinetics of the ankle joint during level walking at normal and fast speeds. In addition, findings were compared with results from the first generation shoe. Fourteen healthy males performed five successful level walking trials in four testing conditions: walking in unstable and control shoes at normal (1.3 m/s) and fast (1.8 m/s) speeds. The unstable shoe resulted in an increase in mediolateral COP displacement, first peak vertical GRF loading rate, braking GRF, ankle eversion range of motion (ROM), and inversion moment; as well as a decrease in anteroposterior COP displacement, second peak vertical GRF, ankle plantarflexion ROM, and dorsiflexion moment. Only minor differences were found between the shoe generations. Results of the generational comparisons suggest that the lower-profile second generation shoe may be as effective at achieving the desired unstable effects while promoting a smoother transition from heel contact through toe off compared with the first generation shoe.

Influence of long-term wearing of unstable shoes on compensatory control of posture: an electromyography-based analysis

PURPOSE

This study investigated the influence of long-term wearing of unstable shoes (WUS) on compensatory postural adjustments (CPA) to an external perturbation.

METHODS

Participants were divided into two groups: one wore unstable shoes while the other wore conventional shoes for 8 weeks. The ground reaction force signal was used to calculate the anterior-posterior (AP) displacement of the centre of pressure (CoP) and the electromyographic signal of gastrocnemius medialis (GM), tibialis anterior (TA), rectus femoris (RF) and biceps femoris (BF) muscles was used to assess individual muscle activity, antagonist co-activation and reciprocal activation at the joint (TA/GM and RF/(BF+GM) pairs) and muscle group levels (ventral (TA+RF)/dorsal (GM+BF) pair) within time intervals typical for CPA. The electromyographic signal was also used to assess muscle latency. The variables described were evaluated before and after the 8-week period while wearing the unstable shoes and barefoot.

RESULTS

Long-term WUS led to: an increase of BF activity in both conditions (barefoot and wearing the unstable shoes); a decrease of GM activity; an increase of antagonist co-activation and a decrease of reciprocal activation level at the TA/GM and ventral/dorsal pairs in the unstable shoe condition. Additionally, WUS led to a decrease in CoP displacement. However, no differences were observed in muscle onset and offset.

CONCLUSION

Results suggest that the prolonged use of unstable shoes leads to increased ankle and muscle groups' antagonist co-activation levels and higher performance by the postural control system.

Footwear recommendations and patterns among orthopaedic foot and ankle surgeons: a survey

BACKGROUND

Foot and ankle surgeons are in a unique position to educate patients about the importance of proper footwear. Neither their recommendations regarding shoe selection nor their own footwear patterns have previously been reported.

METHODS

A total of 866 members of the American Orthopaedic Foot & Ankle Society (AOFAS) were asked to complete a survey via the Internet. Topics included specific shoe brands recommended to patients, how attributes of footwear are communicated, and respondents' footwear habits.

RESULTS

In all, 276 (32%) surgeons responded, and 64% recommended New Balance athletic shoes to patients; 26% did not recommend specific brands. It was found that 50% wear New Balance athletic shoes; 25% wear Nike. Rockport (27%) and SAS (27%) were the most recommended dress shoes. In all, 76% are familiar with AOFAS guidelines for proper shoe fit, but only 56% educated their patients about the guidelines; 43% do not consider what patients might think of their shoes when selecting what to wear in the clinical setting.

CONCLUSIONS

Despite the multitude of different brands, several were commonly recommended. Respondents seem to be aware of the impact of their own shoe selection on patients' perspectives of footwear, but many do not consider themselves role models for proper footwear.

The effect of unstable sandals on instability in gait in healthy female subjects

Unstable footwear generally lacks thorough peer-review published research to support concepts and marketing claims. The purpose of this study was to investigate the instability induced by four (FitFlop, Masai Barefoot Technology, Reebok Easy-Tone and Skechers Tone-Ups) commercially available unstable sandals and one stable control sandal (Earth) in walking in 15 females (mean±SD age was 29±6.7 years, mass 62.6±6.9kg and height 167.1±4.2cm). Three-dimensional motion with synchronised electromyography and kinetic data were collected. Walking speed and step length remained consistent between conditions, however double support time decreased in Masai Barefoot Technology. Centre of pressure data identified no consistent difference between the stable control and the unstable sandals, however Masai Barefoot Technology reduced the anterior-posterior range of centre of pressure. Muscle activity differed significantly at the ankle in the unstable footwear. FitFlop, Reebok and Skechers increased peroneal activity during pre-swing, whereas Masai Barefoot Technology increased medial gastrocnemius and decreased tibialis anterior activity in loading response and mid-stance. The larger rocker sole of the Masai Barefoot Technology altered gait and muscle activation with regard to braking and progression in the sagittal plane. Reebok, Skechers and FitFlop, with softer, less stable foreparts increased evertor action at toe-off, having their effect in the coronal plane. The study highlighted that any instability induced by the shoes is design-specific.

EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis

The objective was to develop evidence -based recommendations and a research and educational agenda for the non-pharmacological management of hip and knee osteoarthritis (OA). The multidisciplinary task force comprised 21 experts: nurses, occupational therapists, physiotherapists, rheumatologists, orthopaedic surgeons, general practitioner, psychologist, dietician, clinical epidemiologist and patient representatives. After a preliminary literature review, a first task force meeting and five Delphi rounds, provisional recommendations were formulated in order to perform a systematic review. A literature search of Medline and eight other databases was performed up to February 2012. Evidence was graded in categories I-IV and agreement with the recommendations was determined through scores from 0 (total disagreement) to 10 (total agreement). Eleven evidence-based recommendations for the non-pharmacological core management of hip and knee OA were developed, concerning the following nine topics: assessment, general approach, patient information and education, lifestyle changes, exercise, weight loss, assistive technology and adaptations, footwear and work. The average level of agreement ranged between 8.0 and 9.1. The proposed research agenda included an overall need for more research into non-pharmacological interventions for hip OA, moderators to optimise individualised treatment, healthy lifestyle with economic evaluation and long-term follow-up, and the prevention and reduction of work disability. Proposed educational activities included the required skills to teach, initiate and establish lifestyle changes. The 11 recommendations provide guidance on the delivery of non-pharmacological interventions to people with hip or knee OA. More research and educational activities are needed, particularly in the area of lifestyle changes.

Influence of wearing an unstable shoe on thigh and leg muscle activity and venous response in upright standing

PURPOSE

To quantify the effect of unstable shoe wearing on muscle activity and haemodynamic response during standing.

METHODS

Thirty volunteers were divided into 2 groups: the experimental group wore an unstable shoe for 8 weeks, while the control group used a conventional shoe for the same period. Muscle activity of the medial gastrocnemius, tibialis anterior, rectus femoris and biceps femoris and venous circulation were assessed in quiet standing with the unstable shoe and barefoot.

RESULTS

In the first measurement there was an increase in medial gastrocnemius activity in all volunteers while wearing the unstable shoe. On the other hand, after wearing the unstable shoe for eight weeks these differences were not verified. Venous return increased in subjects wearing the unstable shoe before and after training.

CONCLUSIONS

The unstable shoe produced changes in electromyographic characteristics which were advantageous for venous circulation even after training accommodation by the neuromuscular system.

Effect of a rocker non-heeled shoe on EMG and ground reaction forces during gait without previous training

Unstable shoes have been designed to promote "natural instability" and during walking they should simulate barefoot gait, enhancing muscle activity and, thus, attributing an advantage over regular tennis shoes. Recent studies showed that, after special training on the appropriate walking pattern, the use of the Masai Barefoot Technology (MBT) shoe increases muscle activation during walking. Our study presents a comparison of muscle activity as well as horizontal and vertical forces during gait with the MBT, a standard tennis shoe and barefoot walking of healthy individuals without previous training. These variables were compared in 25 female subjects and gait conditions were compared using ANOVA repeated measures (effect size:0.25). Walking with the MBT shoe in this non-instructed condition produced higher vertical forces (first vertical peak and weight acceptance rate) than walking with a standard shoe or walking barefoot, which suggests an increase in the loads received by the musculoskeletal system, especially at heel strike. Walking with the MBT shoe did not increase muscle activity when compared to walking with the standard shoe. The barefoot condition was more effective than the MBT shoe at enhancing muscle activation. Therefore, in healthy individuals, no advantage was found in using the MBT over a standard tennis shoe without a special training period. Further studies using the MBT without any instruction over a longer period are needed to evaluate if the higher loads observed in the present study would return to their baseline values after a period of adaptation, and if the muscle activity would increase over time.