Catherine Bowen

Musculoskeletal ultrasound imaging of the plantar forefoot in patients with rheumatoid arthritis: inter-observer agreement between a podiatrist and a radiologist

BackgroundThe use of musculoskeletal ultrasound (MSUS) in the diagnosis and management of foot and ankle musculoskeletal pathology is increasing. Due to the wide use of MSUS and the depth and breadth of training required new proposals advocate tailored learning of the technique to discrete fields of practice. The aims of the study were to evaluate the inter-observer agreement between a MSUS radiologist and a podiatrist, who had completed basic skills training in MSUS, in the MSUS assessment of the forefoot of patients with Rheumatoid Arthritis.MethodsA consecutive sample of thirty-two patients with rheumatoid arthritis was assessed for presence of synovitis, erosions and bursitis within the forefoot using MSUS. All MSUS assessments were performed independently on the same day by a podiatrist and one of two Consultant Radiologists experienced in MSUS.ResultsModerate agreement on image acquisition and interpretation was achieved for bursitis (kappa 0.522; p < 0.01) and erosions (kappa 0.636; p < 0.01) and fair agreement for synovitis (kappa 0.216; p < 0.05) during the primary assessments. Following a further training session, substantial agreement (kappa 0.702) between the two investigators was recorded. The sensitivity of the podiatrist using MSUS was 82.4% for detection of bursitis, 83.0% for detection of erosion and 84.0% for detection of synovitis. Specificity of the podiatrist using MSUS was 88.9% for detection of bursitis, 80.7% for detection of erosion and 35.9% for detection of synovitis.ConclusionThis study demonstrated good inter-observer agreement between a podiatrist and radiologist on MSUS assessment of the forefoot, particularly for bursitis and erosions, in patients with rheumatoid arthritis. There is scope to further evaluate and consider the role of podiatrists in the MSUS imaging of the foot following appropriate training and also in the development of reliable protocols for MSUS assessment of the foot.

Prognostic indicators of foot-related disability in patients with rheumatoid arthritis: results of a prospective three-year study.

To determine the prevalence and natural history of foot‐related disability in patients with rheumatoid arthritis (RA). A secondary aim was to identify explanatory variables, including forefoot bursae, that are either associated with or predictive of disabling foot complications in patients with RA.

Guidelines for the management of people with foot health problems related to rheumatoid arthritis: a survey of their use in podiatry practice

BackgroundIn the last decade there has been a significant expansion in the body of knowledge on the effects of rheumatoid arthritis (RA) on the foot and the management of these problems. Aligned with this has been the development of specialist clinical roles for podiatrists. However, despite being recommended by national guidelines, specialist podiatrists are scarce. In order to inform non-specialist podiatrists of the appropriate interventions for these foot problems, management guidelines have been developed and disseminated by a group of specialist podiatrists. The aim of this survey was to investigate the use of these guidelines in clinical practice.MethodFollowing ethical approval an online questionnaire survey was carried out. The questions were formulated from a focus group and comprised fixed response and open response questions. The survey underwent cognitive testing with two podiatrists before being finalised. An inductive approach using thematic analysis was used with the qualitative data.Results245 questionnaires were completed (128–non-specialist working in the private sector, 101 non–specialists working in the NHS and 16 specialist podiatrists). Overall, 97% of the non-specialists (n = 222) had not heard of the guidelines. The non-specialists identified other influences on their management of people with RA, such as their undergraduate training and professional body branch meetings. Three main themes emerged from the qualitative data: (i) the benefits of the foot health management guidelines, (ii) the barriers to the use of guidelines generally and (iii) the features of useable clinical guidelines.ConclusionsThis study has revealed some crucial information about podiatrists’ level of engagement with the foot health management guidelines and the use of guidelines in general. Specifically, the non-specialist podiatrists were less likely to use the foot health management guidelines than the specialist podiatrists. The positive aspects were that for the specialist practitioners, the guidelines helped them to identify their professional development needs and for the few non-specialists that did use them, they enabled appropriate referral to the rheumatology team for foot health management. The barriers to their use included a lack of understanding of the risk associated with managing people with RA and that guidelines can be too long and detailed for use in clinical practice. Suggestions are made for improving the implementation of foot health guidelines.

Assessment of the natural history of forefoot bursae using ultrasonography in patients with rheumatoid arthritis: a twelve-month investigation.

To determine the natural history and clinical significance of forefoot bursae over a 12‐month period in patients with rheumatoid arthritis (RA).

Associations between body mass index and foot joint pain in middle-aged and older women: a longitudinal population-based cohort study.

To investigate the relationship between body mass index (BMI) and foot joint pain (FJP) over a 5‐year period in a community‐based cohort.

Forefoot pathology in rheumatoid arthritis identified with ultrasound may not localise to areas of highest pressure: cohort observations at baseline and twelve months

BackgroundPlantar pressures are commonly used as clinical measures, especially to determine optimum foot orthotic design. In rheumatoid arthritis (RA) high plantar foot pressures have been linked to metatarsophalangeal (MTP) joint radiological erosion scores. However, the sensitivity of foot pressure measurement to soft tissue pathology within the foot is unknown. The aim of this study was to observe plantar foot pressures and forefoot soft tissue pathology in patients who have RA.MethodsA total of 114 patients with established RA (1987 ACR criteria) and 50 healthy volunteers were assessed at baseline. All RA participants returned for reassessment at twelve months. Interface foot-shoe plantar pressures were recorded using an F-Scan® system. The presence of forefoot soft tissue pathology was assessed using a DIASUS musculoskeletal ultrasound (US) system. Chi-square analyses and independent t-tests were used to determine statistical differences between baseline and twelve months. Pearsons correlation coefficient was used to determine interrelationships between soft tissue pathology and foot pressures.ResultsAt baseline, RA patients had a significantly higher peak foot pressures compared to healthy participants and peak pressures were located in the medial aspect of the forefoot in both groups. In contrast, RA participants had US detectable soft tissue pathology in the lateral aspect of the forefoot. Analysis of person specific data suggests that there are considerable variations over time with more than half the RA cohort having unstable presence of US detectable forefoot soft tissue pathology. Findings also indicated that, over time, changes in US detectable soft tissue pathology are out of phase with changes in foot-shoe interface pressures both temporally and spatially.ConclusionsWe found that US detectable forefoot soft tissue pathology may be unrelated to peak forefoot pressures and suggest that patients with RA may biomechanically adapt to soft tissue forefoot pathology. In addition, we have observed that, in patients with RA, interface foot-shoe pressures and the presence of US detectable forefoot pathology may vary substantially over time. This has implications for clinical strategies that aim to offload peak plantar pressures.

A systematic review of the key factors affecting tissue viability and rehabilitation outcomes of the residual limb in lower extremity traumatic amputees

Most traumatic lower limb amputees ambulate using a prosthetic limb. Comfort, appearance of the missing limb and function are confirmed as being important during rehabilitation post-amputation. Emerging evidence suggests that impaired tissue viability of the stump affects rehabilitation and thus clinical ability to provide optimum care. The primary objective of this systematic review was to identify key factors relating to tissue viability of the residual limb in lower extremity traumatic amputees. A secondary objective was to identify factors that affect rehabilitation post-amputation. In total, 218 studies were assessed; 37 met pre-determined criteria. Studies were classified according to the WHO ICF framework and the NHMRC level of evidence. Five key themes emerged; Prosthetic Fit; The Residuum; Quality of Life; Amputee Care and Prosthetic Use. The evidence indicates that high frequencies of skin problems affecting tissue viability within this population are inherently linked to intolerance of the prosthesis. Stump integrity, amputee care regimen and pain were also identified as impacting on quality of life, affecting rehabilitation and the ability to become independently mobile. Levels of evidence within all studies were low and indicative of the majority being non-randomised cohort studies or case-control studies. As there are a limited number of interventional studies, further development of robust outcome measures, clinical trials and prospective studies are of utmost importance to unravel the links between tissue viability and the other key factors. This will inform clinical management strategies and help develop targeted therapies and care pathways.

Improvement in symptoms and signs in the forefoot of patients with rheumatoid arthritis treated with anti-TNF therapy

BackgroundInhibition of tumour necrosis factor (TNF) is an effective way of reducing synovitis and preventing joint damage in rheumatoid arthritis (RA), yet very little is known about its specific effect on foot pain and disability. The aim of this study was to evaluate whether anti-TNF therapy alters the presence of forefoot pathology and/or reduces foot pain and disability.MethodsConsecutive RA patients starting anti-TNF therapy (infliximab, etanercept, adalimumab) were assessed for presence of synovial hypertrophy and synovitis in the 2nd and 5th metatarso-phalangeal (MTP) joints and plantar forefoot bursal hypertrophy before and 12 weeks after therapy. Tender MTP joints and swollen bursae were established clinically by an experienced podiatrist and ultrasound (US) images were acquired and interpreted by a radiologist. Assessment of patient reported disease impact on the foot was performed using the Manchester Foot Pain and Disability Index (MFPDI).Results31 patients (24 female, 7 male) with RA (12 seronegative, 19 seropositive) completed the study: mean age 59.6 (SD 10.1) years, disease duration 11.1 (SD 10.5) years, and previous number of Disease Modifying Anti Rheumatic Drugs 3.0 (1.6). Significant differences after therapy were found for Erythrocyte Sedimentation Rate (t = 4.014, p < 0.001), C-reactive protein (t = 3.889, p = 0.001), 28 joint Disease Activity Score (t = 3.712, p = 0.0001), Visual Analog Scale (t = 2.735, p = 0.011) and Manchester Foot Pain and Disability Index (t = 3.712, p = 0.001).Presence of MTP joint synovial hypertrophy on US was noted in 67.5% of joints at baseline and 54.8% of joints at twelve weeks. Presence of plantar forefoot bursal hypertrophy on US was noted in 83.3% of feet at baseline and 75% at twelve weeks. Although there was a trend for reduction in observed presence of person specific forefoot pathology, when the frequencies were analysed (McNemar) this was not significant.ConclusionsSignificant improvements were seen in patient reported foot pain and disability 12 weeks after commencing TNF inhibition in RA, but this may not be enough time to detect changes in forefoot pathology.

Use of Quantitative Ultrasound Scans of the Calcaneus to Diagnose Osteoporosis in Patients with Rheumatoid Arthritis

BACKGROUND Patients with rheumatoid arthritis are recognized as being at risk for osteoporosis as a result of the disease process as well as the medication used to treat it. This study was conducted to consider the use of calcaneal scanning with quantitative ultrasound-contact ultrasound bone analysis (CUBA)-to diagnose osteoporosis in patients with rheumatoid arthritis. METHODS Forty-six patients (11 men and 35 women) with established rheumatoid arthritis underwent dual-energy x-ray absorptiometry (DEXA) of the nondominant wrist and CUBA of the nondominant heel. Sensitivity, specificity, and positive and negative predictive values were used to determine the correlation between osteoporosis as diagnosed by the CUBA heel scan compared with the DEXA wrist scan given that DEXA is widely seen as the gold standard for the diagnosis of osteoporosis. RESULTS The CUBA heel scan revealed a sensitivity of 90% and a specificity of 44% for a diagnosis of osteoporosis compared with DEXA. The positive predictive value of the CUBA scan was 31%, and the negative predictive value was 94%. Therefore, if normal bone density is found using CUBA, there is 94% certainty this is correct. However, if osteoporosis is diagnosed using CUBA, there is only 31% certainty this is correct. In such instances a secondary scan using a different method (eg, DEXA) would be required. Future work should consider the effect of minor alterations to the equipment or scanning protocol, because this may improve diagnosis. CONCLUSIONS The CUBA unit could be used as a primary screening device. Given the cost and accessibility issues associated with DEXA, quantitative ultrasound may have a role in screening for osteoporosis in the primary-care setting to determine the most appropriate routes of referral for patients requiring further investigations.

JFAR's role in publishing believable research findings

Health research published in journals provides an ever-increasing number of studies and trials that espouse the benefits of all sorts of interventions. But how do consumers of research, for example the readers of Journal of Foot and Ankle Research (JFAR), know whether to believe the findings of research articles that they read? Clearly, health journals have an unambiguous responsibility to support good quality research that provides believable findings. Equally, they also have a responsibility to filter out poor quality research that provides findings that are not believable. JFAR steadfastly supports good quality research and the editorial team (with the assistance of the peer-reviewers) work conscientiously to publish only those studies that are of the highest quality; that is, studies with believable findings. While this is not always easy, and the goal posts that define quality of research are constantly being repositioned, the editors strive to bring the readers of JFAR the best foot and ankle research. Unfortunately, not all studies use perfect methods, so if a study does have limitations and is published, then the editors are careful to ensure that the authors clearly acknowledge the limitations in their articles, affording readers an insight into the pitfalls of the study. To assist the editors in this task, there is a burgeoning array of guidelines and recommendations for the conduct and reporting of different study designs. For example, there are the CONsolidated Standards Of Reporting Trials (CONSORT) Statement [1] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [2]. Each guideline has been developed to ensure that important aspects of a trial or review are reported by the authors. To assist in this process, there is a checklist for each item in the guideline, which covers key aspects of a study (e.g. blinding, sample size determination and statistical analysis) that authors should report to ensure that they have included essential pieces of information, which ultimately makes the study’s findings more believable. That is, it prevents authors from deceiving the reader, by concealing that they did not do something they should have, or equally bad, done something that they should not have. As an added bonus to readers of such articles, if guidelines like CONSORT and PRISMA are followed they invariably make an article less ambiguous and much easier to understand what has occurred in the study. The developers of such guidelines are experts, with most having decades of highly active experience researching and practicing these study designs. They are also generous individuals that have provided the guidelines in consumer friendly packages that are freely available. Potential users of these guidelines can easily access them through the well-developed CONSORT [3] and PRISMA [4] websites. Further to the guidelines mentioned above, there are many others for different study designs, for example; the Guidelines for Reporting Reliability and Agreement Studies (GRRAS) [5] and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [6,7]. Authors are recommended to consult these where appropriate and an excellent resource when writing manuscripts is that of the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network [8], which is a virtual one-stop shop for guidelines that are relevant to publishing in health science journals. The EQUATOR Network includes guidelines for both quantitative and qualitative research. JFAR, as a BioMed central journal, adheres to these guidelines and authors of studies that use these study designs are obliged to include such checklists upon submission of their article. Few foot and ankle journals ensure this or even worse, do not even recommend this. However, JFAR is setting the benchmark in this area because the editors believe that it leads to the highest possible quality research articles for its readers, and consequently the most believable findings will be presented in JFAR. Furthermore, if clinical trials – where participants receive an intervention that is evaluated – are considered in more detail, JFAR also demands that authors must register their trial with a recognised clinical trial registry. Ideally, clinical trials should be registered prior to recruitment. Up to now, JFAR has accepted clinical trials that have been registered with a recognised clinical trial registry after the first participant has been recruited. However, from now on, JFAR will only accept clinical trials that are registered prior to recruitment. Why is this important? To begin with, it means that all clinical trials can be tracked and the results of clinical trials are less likely to be not published, which occurs more frequently in ‘non-significant trials’ (where no difference is detected between interventions). However, an equally important reason is that it prevents investigators changing their protocol or analysis in light of their findings if they unwisely assess the results prior to the completion of the trial, or once they have evaluated the results but before publication (often referred to as over-analysing the data or “cherry-picking” the results, which results in bias). By default, this means that investigators have to commit to their protocol and analysis, thus keeping them honest, which again leads to more believable findings. There are many recognised clinical trial registries and a list of recommended registries can be found on the International Committee of Medical Journal Editors website (http://www.icmje.org/publishing_j.html). With all of this information in mind, two key points need to be considered. Firstly, consumers of articles that are published in JFAR should be assured that they are reading articles that present findings from high quality research. Secondly, potential authors of research manuscripts being submitted to JFAR need to adhere to the standards set by the journal; that is, they must read the guidelines for authors and carefully follow them when preparing their manuscripts. The journal’s guidelines are clear (http://www.jfootankleres.com/authors/instructions/research) and it is now, more than ever, not acceptable for authors to plead ignorance. As the impact of JFAR continues to increase, the editors are receiving more and more manuscripts to be considered for publication. This allows the editors more freedom to choose only the best quality research articles. If a manuscript is poorly written at the outset – for example, it has not adhered to the journal’s guidelines – then it has a much greater chance of rejection. Currently, JFAR rejects over 40% of the manuscripts submitted to it, and this figure is rising as the journal becomes more popular. For the best health journals in the world, such as New England Journal of Medicine and Lancet, this figure is about 95%. This means that they only publish the highest quality research. While there are exceptions, this research will generally be the most believable and will have the most impact. In conclusion, the editors of JFAR work hard to ensure that they provide a vehicle for the best quality foot and ankle research. While a small number of mistakes will undoubtedly be made and errors detected only after publication, readers can be assured that JFAR is trying to set the highest standards possible to foster a culture of believable research. We trust that readers of the journal can appreciate that such standards lead to better, more believable information for them. Some may view this as being elitist or exclusive, but if this is the price for believable research findings then that is a label the editors are prepared to wear. Conducting good research is not easy, and clear evidence can sometimes take years to compile (take the evidence for the ill-effects of tobacco smoking as a perfect example). Journals that follow an easy formula, where there are few checks and balances, ultimately provide a ‘fast food’ approach to health information – it may look fabulous and satiate ones appetite for knowledge easily, but it is not good for anyone in the long term. Professional journals have a responsibility to ensure that statements made in manuscripts can be supported by the study findings (i.e. good-quality evidence). This responsibility should not be viewed as being elitist or exclusive and in no way suppresses freedom of expression. Indeed, the fundamental premise of scientific publication is the reporting of empirically verifiable facts, which means believable information.