Margaret. Hodge

Orthotic management of plantar pressure and pain in rheumatoid arthritis

OBJECTIVE To investigate the effectiveness of foot orthoses in the management of plantar pressure and pain in subjects with rheumatoid arthritis. DESIGN A repeated measures study in which the independent variable was orthosis design. Dependent variables, including pressure, gait and pain parameters, were examined using analysis of variance and correlation statistics. BACKGROUND The aim of orthotic management of the rheumatoid foot is to relieve metatarsalgia through the reduction of metatarsal head pressure. Few studies have investigated the relative effectiveness of different orthosis designs. To date, no studies have examined the relationship between plantar pressure and second metatarsal head pain in rheumatoid arthritis subjects. METHODS Twelve rheumatoid arthritis subjects with foot involvement and second metatarsal head pain were tested. Four styles of foot orthosis (prefabricated, standard custom moulded, custom with metatarsal bar, custom with metatarsal dome) were compared to a shoe only control. An EMED Pedar system was used to measure plantar pressure during repeated trials of comfortable cadence walking and quiet standing. Reports of subjective pain were recorded for each orthosis as were orthosis preferences. RESULTS All orthoses significantly reduced pressure beneath the first and second metatarsal heads compared to the shoes only control. The custom moulded orthosis with metatarsal dome was the most effective orthosis for reducing subjective ratings of pain. A significant correlation (r=0.562) was found between ratings of pain and average pressure beneath the second metatarsal head. CONCLUSIONS Results from this study suggest that average pressure measurement may be a useful indicator in the management of metatarsalgia in RA. Further study is required to improve understanding of the relationship between rheumatoid foot mechanics and pain. RELEVANCE Appropriate foot orthosis design can substantially improve comfort in RA patients with symptomatic feet. A custom moulded foot orthosis incorporating a metatarsal dome was the most effective design for subjects with painful second metatarsal heads. Foot pressure measurement technology can be a useful adjunct to research and clinical management of the painful rheumatoid foot.

Biomechanics of Ambulation after Partial Foot Amputation: A Systematic Literature Review.

The purpose of this systematic review was to establish what is known about gait and prosthetic/orthotic intervention in persons with partial foot amputation (PFA) and to identify what needs to be known to optimize gait and prosthetic/orthotic intervention. A systematic search of the literature identified 437 citations, with 28 publications selected for review based on inclusion criteria. Studies analyzing the gait of PFA were generally published in the last two decades in a myriad of journals spanning many disciplines. Publications that met the inclusion criteria were predominantly classified as case-control or cross-sectional studies and were reviewed based on various aspects of the biomechanics of gait, including temporospatial, ground reaction force (GRF), center of pressure (CoP) excursion, kinematics, kinetics, plantar pressure, electromyography, and energy expenditure. Studies reporting results for each variable were described, methodological issues identified and discussed, and the results summarized. The quality of the evidence was then rated as high, moderate, low, or insufficient for a number of outcome statements based on the various aspects of the biomechanics of gait. Overall, there was a high level of evidence that PFA generally affects temporospatial, GRF, ankle kinetics, and plantar pressures during gait, but there was less confidence in the evidence regarding more detailed statements about exactly how these aspects of gait are affected by PFA. This is reflective of the small and heterogenous populations included in the reviewed literature. Because the studies were largely observational, there is insufficient evidence regarding the efficacy of specific prosthetic and orthotic interventions, although generally there was low to moderate evidence that prosthetic and orthotic interventions affect ankle kinematics and moments and may moderate CoP progression. There remains the need to further our understanding of the biomechanics of PFA gait and establish hypotheses regarding prosthetic and orthotic requirements for improved ambulation/function and protection of the residuum.

Plantar pressure pain thresholds and touch sensitivity in Rheumatoid Arthritis

Background: In-shoe pressure redistribution to provide relief of forefoot pain in rheumatoid arthritis (RA) is based on assumed links between pressure and pain. However, little is known about the size of the pressure change required to reduce pain or the capacity of other plantar regions to bear increased pressure. Our primary aim was to quantify the plantar pressure pain threshold (PPT) in RA and compare it to age- and gender-matched control participants. Materials and Methods: This controlled trial involved 10 RA participants and 10 age- and gender-matched control subjects. PPT, measured using a force gauge, and touch sensitivity, measured via Semmes-Weinstein monofilaments, were tested in 19 plantar regions. Results: RA plantar PPTs were significantly reduced in eight foot regions (p < 0.05) and were more uniform across the plantar surface. Touch sensitivity was not different between groups. Plantar PPT was significantly related to age (p < 0.05) and to touch sensitivity (p < 0.05) in multiple foot regions of the control group but not in RA. PPT was significantly correlated with disease duration (p < 0.05). Conclusion: Plantar PPTs in RA were 60% to 80% of the control group and may be helpful in predicting the amount of pressure reduction needed to relieve pain. This study provides further evidence that RA disturbs normal pain sensory mechanisms. Level of Evidence: III, Retrospective Case Control

The Prosthetist Role Expectations Scale: Development and initial validation of a scale for clinical settings

Background: The role of the prosthetist has changed substantially over the past century. In the transition from ‘limb-maker’ to ‘clinician’, the expectations of prosthetics professionals have also changed. Objectives: To develop and test a new scale capable of assessing and comparing current expectations of the roles of the prosthetist. Study design: Scale development and validation. Methods: A new scale was constructed in accordance with Organizational Role Theory. It comprised 72 items that subdivide into 11 subscales. Face, content and construct validity, along with test–retest and inter-rater reliability were evaluated. Results: The Prosthetist Role Expectations Scale was found to be psychometrically sound, reliable for use in a range of settings and clinically feasible in a sample of 17 Australian therapists. Conclusion: The Prosthetist Role Expectations Scale demonstrated robust psychometric properties and appears well suited to monitoring current expectations of the role of the prosthetist in health service delivery. Clinical relevance The Prosthetist Role Expectations Scale can identify current expectations of the role of the prosthetist, showing areas of consensus and conflict between key professional and client groups. Wider use of the instrument will contribute to increased understanding of professional roles. This may help to reduce role conflict and improve communication within healthcare teams.

Bagherzadeh Cham et al. Prosth Orthot Int 2014; 38: 310-315.

We write with regard to the recent publication by Bagherzadeh Cham et al.1 to highlight a number of methodological issues that reduce our confidence in the authors’ conclusion that a rocker shoe can reduce pain, disability, and activity limitation in people with rheumatoid arthritis (RA). We are concerned that the Foot Function Index (FFI) scores are unusually low when compared to similar investigations.2–4 We suggest two sources of error with the scoring of this instrument. First, the authors describe scoring the visual analogue scales (VAS) of the FFI from 0 to 10,1 citing the work by Budiman-Mak et al.5 in support of their approach. Budiman-Mak et al.5 describe that the FFI is scored by dividing each VAS into 10 equal segments and assigning a number ranging from 0 to 9 to each segment.5 This difference in scoring would account for a 10% error, equivalent to the minimum clinically important difference for the FFI.6 Second, we expect the authors have not multiplied scores by 100 to eliminate the decimal point,5 thus explaining why the FFI values are about one-tenth that reported in similar publications.2–4 Given the aim of the study was “... to evaluate the effect of heel-to-toe rocker shoe on pain, disability and activity limitation in RA patients immediately, 7 and 30 days after their first visit,”1 we were surprised that FFI subscale scores were also compared, over time, in groups based on the region of pain (i.e. forefoot, rearfoot, and ankle pain groups). Unfortunately, these groups were not independent; that is, participants were included in more than one group. Nearly all participants (16/17) had forefoot pain and were grouped accordingly. Many of these participants (10/17) were also included in the ankle pain group (10/17) and a rearfoot pain group (6/17). Grouping participants this way biases our understanding of how the FFI scores change over time in people with pain in different regions, because many of the same FFI scores were included in more than one group. A better design would ensure the independence of groups by forming them based on each participant’s most painful region, as an illustrative example. In this way, the most painful region could be included as an independent variable in a more sophisticated inferential analysis that would separate the effect of the painful region from that of time. A more sophisticated analysis would also be warranted, given the relationship between the dependent variables. If the assumptions of a multiple analysis of variance (MANOVA) were met, this analysis could control for the influence that changes in the FFI subscale scores have on each other and the FFI total score. With a more robust statistical technique, we wonder whether the differences observed in the FFI disability or FFI activity limitation subscales would be statistically significant. We were disappointed that complete details of the inferential analysis were not reported, such as the type of post hoc test used, if any. More complete reporting should include the F ratio, degrees of freedom, p values, and effect size, as well as the results of the post hoc comparisons. With these additional details, we hope to affirm our assessment of the descriptive data (Table 4) that indicates the FFI scores declined significantly between the initial and 7-day visits, but not between the 7-day and 30-day visits. This has important implications for the accuracy of the discussion which implies that changes in the FFI scores occurred over the 7and 30-day periods: “... use of high-top rocker shoes with wide toe box significantly decreased pain, disability and activity limitation ... in the RA patient with foot problems after 7 and 30 days follow-up.”1 Our final concern is that the clinical implications and conclusions do not fairly acknowledge that participants were in the early stage of the disease process, and therefore, atypical of people living with RA who would usually be prescribed rocker shoes. Subjects in the study were all female, relatively young (47.2 ± 8.1 years), without fixed deformities, in remission (disease activity score 28: 1.7 ± 1.0), and had short disease duration (7.88 ± 7.2 years). The representativeness of the sample is an important limitation to acknowledge, so the findings of this work can be fairly applied to people in the early stage of the disease, not those with the advanced deformities who would normally receive such footwear and rocker soles. We encourage Bagherzadeh Cham and colleagues to rectify the errors with FFI scoring and to republish their data with more complete reporting of the results, including post hoc analysis. We hope the findings of this investigation can then contribute to the growing body of evidence Bagherzadeh Cham et al. Prosth Orthot Int 2014; 38: 310–315 568415 POI0010.1177/0309364614568415Prosthetics and Orthotics InternationalDillon and Hodge research-article2015

Valma Angliss, member of the order of Australia

Valma Angliss was appointed Chief Occupational Therapist at the Royal Childrens Hospital in Melbourne, Australia in 1958, when she was only 26 years old. As an occupational therapist working with limb deficient children, Valma saw a close relationship between her profession, medicine and prosthetics/orthotics. It is therefore not surprising that her interests perfectly matched the philosophy of the International Society for Prosthetics and Orthotics. She became one of its earliest members, participating actively with papers and seminars in Australia and Overseas. Valma was the ISPO Australian Secretary for many years, then Chairman, and contributed significantly to the establishment and growth of the Australian national Member Society. In recognition of her work for the society, in 1978 Valma was appointed a Fellow of ISPO. In 1985 she was elected to the International Executive Board. As quite an extraordinary member, she represented four important minorities: being a woman, being Australian, being an occupational therapist and attending the meetings at her own expense. Her remarkable dedication, her expertise, her unique blend of charm, patience and energy, combined with a slight dose of stubbornness convinced the Society to stage the 1995 8th ISPO World Congress in Melbourne, with Valma as Secretary General. This event was an outstanding success with some 2000 participants from all over the world. ISPO honoured Valma in 1997, by appointing her as Honorary Fellow. Five years later, Australia recognised her meritorious service to her country with the honour of Member of the Order of Australia (AM). Congratulations, Valma!