Sara Jones

Comparison of the clinical effectiveness of different off‐loading devices for the treatment of neuropathic foot ulcers in patients with diabetes: a systematic review and meta‐analysis

Effective off‐loading is considered to be an important part of the successful clinical management of diabetic foot ulcers. The aim of this systematic review is to investigate the safety and effectiveness of different off‐loading devices for the treatment of diabetic foot ulcers. The medical literature was extensively searched from January 1966 to May 2012. Systematic reviews and controlled studies that compared the use of different off‐loading devices formed the evidence base. Studies were critically appraised to determine their risk of methodological bias, and data were extracted. Results were pooled using random effects meta‐analysis and tested for heterogeneity. When compared with removable devices, non‐removable off‐loading devices were found, on average, to be more effective at promoting the healing of diabetic foot ulcers (RRp = 1.43; 95% CI 1.11, 1.84; I2 = 66.9%; p = 0.001; k = 10). Analysis, stratified by type of removable device, did not detect a statistically significant difference between non‐removable off‐loading devices and removable cast walkers; however, on average non‐removable off‐loading devices performed better than therapeutic shoes at promoting the healing of diabetic foot ulcers (RRp = 1.68; 95% CI 1.09, 2.58; I2 = 71.5%; p = 0.004; k = 6). The two types of non‐removable off‐loading devices i.e. total contact casts and instant total contact casts (removable cast walker rendered irremovable by securing with bandage or lace), were found to be equally effective (RRp = 1.06; 95% CI 0.88, 1.27; I2 = 3.3%; p = 0.31; k = 2). In conclusion, non‐removable off‐loading devices regardless of type, are more likely to result in ulcer healing than removable off‐loading devices, presumably because patient compliance with off‐loading is facilitated. Copyright

Sever's Disease: What Does the Literature Really Tell Us?

BACKGROUND Severs disease is typical of many musculoskeletal conditions where observational annotations have slowly been accepted as fact with the passing of years. Acceptance of these nontested observations means that health professionals seeking information on this condition access very low-level evidence, mainly being respectable opinion or poorly conducted retrospective case series. METHODS A comprehensive review of the literature was undertaken gathering available articles and book references relating to Severs disease. This information was then reviewed to present what is actually known about this condition. RESULTS Respectable opinion and poorly conducted retrospective case series make up the majority of evidence on this condition. CONCLUSION The level of evidence for most of what we purport to know about Severs disease is at such a level that prospective, well-designed studies are a necessity to allow any confidence in describing this condition and its treatment.

Differences in foot kinematics between young and older adults during walking

Our understanding of age-related changes to foot function during walking has mainly been based on plantar pressure measurements, with little information on differences in foot kinematics between young and older adults. The purpose of this study was to investigate the differences in foot kinematics between young and older adults during walking using a multi-segment foot model. Joint kinematics of the foot and ankle for 20 young (mean age 23.2 years, standard deviation (SD) 3.0) and 20 older adults (mean age 73.2 years, SD 5.1) were quantified during walking with a 12 camera Vicon motion analysis system using a five segment kinematic model. Differences in kinematics were compared between older adults and young adults (preferred and slow walking speeds) using Students t-tests or if indicated, Mann-Whitney U tests. Effect sizes (Cohens d) for the differences were also computed. The older adults had a less plantarflexed calcaneus at toe-off (-9.6° vs. -16.1°, d = 1.0, p = <0.001), a smaller sagittal plane range of motion (ROM) of the midfoot (11.9° vs. 14.8°, d = 1.3, p = <0.001) and smaller coronal plane ROM of the metatarsus (3.2° vs. 4.3°, d = 1.1, p = 0.006) compared to the young adults. Walking speed did not influence these differences, as they remained present when groups walked at comparable speeds. The findings of this study indicate that independent of walking speed, older adults exhibit significant differences in foot kinematics compared to younger adults, characterised by less propulsion and reduced mobility of multiple foot segments.

The impact of increasing body mass on peak and mean plantar pressure in asymptomatic adult subjects during walking

Introduction : The implication of high peak plantar pressure on foot pathology in individuals both with and without diabetes has been recognized. The aim of this study was to investigate and clarify the relationship between increasing body mass and peak and mean plantar pressure in an asymptomatic adult population during walking. Methods : Thirty adults without any relevant medical history, structural foot deformities or foot posture assessed as highly pronated or supinated, and within a normal body mass index range were included in the study. An experimental, same subjects, repeated measures design was used. Peak and mean plantar pressure were evaluated with the F-Scan in-shoe plantar pressure measurement system under four different loading conditions (0, 5, 10, and 15 kg) simulated with a weighted vest. Pressure data were gathered from three stances utilizing the mid-gait protocol. Results : There were statistically significant increases in peak pressure between the 10 and 15 kg load conditions compared to the control (0 kg) within the heel and second to fifth metatarsal regions. The first metatarsal and hallux regions only displayed statistically significant increases in peak pressure between 15 kg and the control (0 kg). The midfoot and lesser digits regions did not display any statistically significant differences in peak pressure between any load conditions compared to the control (0 kg). The second to fifth metatarsal region displayed statistically significant increases in mean pressure in the 5, 10 and 15 kg groups compared to the control (0 kg). A statistically significant increase in peak pressure between the 15 kg and control (0 kg) group was evident in all other regions. Conclusion : The relationship between increasing body mass and peak and mean plantar pressure was dependent upon the plantar region. This study provides more detail outlining the response of peak and mean pressure to different loading conditions than previously reported in the literature. Further research including measurement of temporal parameters is warranted.

Repeatability of stance phase kinematics from a multi-segment foot model in people aged 50 years and older

Confidence in 3D multi-segment foot models has been limited by a lack of repeatability data, particularly in older populations that may display unique functional foot characteristics. This study aimed to determine the intra and inter-observer repeatability of stance phase kinematic data from a multi-segment foot model described by Leardini et al. [2] in people aged 50 years or older. Twenty healthy adults participated (mean age 65.4 years SD 8.4). A repeated measures study design was used with data collected from four testing sessions on two days from two observers. Intra (within-day and between-day) and inter-observer coefficient of multiple correlations revealed moderate to excellent similarity of stance phase joint range of motion (0.621-0.975). Relative to the joint range of motion (ROM), mean differences (MD) between sessions were highest for the within-day comparison for all planar ROM at the metatarsus-midfoot articulation (sagittal plane ROM 5.2° vs. 3.9°, MD 3.1°; coronal plane ROM 3.9 vs. 3.1°, MD 2.3°; transverse plane ROM 6.8° vs. 5.16°, MD 3.5°). Consequently, data from the metatarsus-midfoot articulation in the Istituto Ortopedico Rizzoli (IOR) foot model in adults aged over 50 years needs to be considered with respect to the findings of this study.

Sever’s disease—Does it effect quality of life?

BACKGROUND Severs disease is a condition which has been described inconsistently in the literature with respect to pathology, aetiology and management. In particular, the impact of this condition has been overlooked, probably because it is usually self-limiting. METHOD This study used a prospective comparative design study to determine the impact of Severs disease on the quality of life of its sufferers. RESULTS Three scales--Happiness, Satisfaction with symptoms and Pain/comfort scale--from the POSNA musculoskeletal questionnaire showed significant differences between the symptomatic and control groups. CONCLUSION Although the condition may resolve with time, these results show that it has a considerable impact on childrens lives.

Who Cares About Foot Care? Barriers and Enablers of Foot Self-care Practices Among Non-Institutionalized Older Adults Diagnosed With Diabetes: An Integrative Review

Purpose Appropriate and timely foot self-care practices may prevent diabetes-related foot complications. However, self-care practices are often neglected, particularly by older adults. The purpose of this study was to conduct an integrative, systematic literature review of the psychosocial barriers and enablers of foot self-care practices among older adults diagnosed with diabetes. Methods An integrative, systematic literature review and a deductive thematic analysis was conducted to determine psychosocial barriers and enablers of foot self-care practices among older adults. Results A total of 130 different studies were retrieved from the search strategy. From these, 9 studies were identified and included for review. Physical ability, perceived importance, patient knowledge, provision of education, social integration, risk status, and patient-provider communication were identified as key barriers and enablers of foot self-care. Participants at high risk of foot complications were found to perceive themselves at greater risk of complications, receive more education, and engage in better overall foot self-care practices compared to those at low risk of foot complications. Conclusion Foot self-care practices appear underutilized as primary prevention measures by older adults and are instead adopted only once complications have already occurred. Likewise, facilitators of foot self-care practices, such as education, appear to be reserved for individuals who have already developed foot complications. Health care professionals such as diabetes educators, podiatrists, and general practitioners may play an important role in the prevention of foot complications among older adults by recognizing, referring, and providing early education to older adults.

Sever's disease: a prospective study of risk factors.

BACKGROUND Severs disease, also known as calcaneal apophysitis, is thought to be an inflammation of the apophysis of the heel, which is open in childhood. This condition has been commented on and looked at in a retrospective manner but has not been examined systematically. We assembled the most commonly cited theoretical causative models identified from the literature and tested them to determine whether any were risk factors. METHODS Children with Severs disease were compared with a similarly aged nonsymptomatic population to determine whether identifiable risk factors exist for the onset of Severs disease. Areas raised in the literature and, hence, compared were biomechanical foot malalignment, as measured by Root et al-type foot measurements and the Foot Posture Index; ankle joint dorsiflexion, measured with a modified apparatus; body mass index; and total activity and types of sport played. RESULTS Statistically significant but small odds ratios were found in forefoot to rearfoot determination and left ankle joint dorsiflexion. CONCLUSIONS This study suggests that there is no evidence to support that weight and activity levels are risk factors for Severs disease. The statistically significant but clinically negligible odds ratio (0.93) on the left side for decreased ankle joint dorsiflexion and statistically significant and clinically stronger odds ratio bilaterally for forefoot to rearfoot malalignment suggest that biomechanical malalignment is an area for further investigation.

Improvements in knee biomechanics during walking are associated with increased physical activity after total knee arthroplasty

Total knee arthroplasty (TKA) in people with knee osteoarthritis increases knee‐specific and general physical function, but it has not been established if there is a relationship between changes in these elements of functional ability. This study investigated changes and relationships between knee biomechanics during walking, physical activity, and use of time after TKA. Fifteen people awaiting TKA underwent 3D gait analysis before and six months after surgery. Physical activity and use of time were determined in free‐living conditions from a high resolution 24‐h activity recall. After surgery, participants displayed significant improvements in sagittal plane knee biomechanics and improved their physical activity profiles, standing for 105 more minutes (p = 0.001) and performing 64 min more inside chores on average per day (p = 0.008). Changes in sagittal plane knee range of motion (ROM) and peak knee flexion positively correlated with changes in total daily energy expenditure, time spent undertaking moderate to vigorous physical activity, inside chores and passive transport (r = 0.52–0.66, p = 0.005–0.047). Restoration of knee function occurs in parallel and is associated with improvements in physical activity and use of time after TKA. Increased functional knee ROM is required to support improvements in total and context specific physical activity.

Altered dynamic foot kinematics in people with medial knee osteoarthritis during walking: A cross-sectional study

BACKGROUND Footwear and insoles are used to reduce knee load in people with medial knee osteoarthritis (OA), despite a limited understanding of foot function in this group. The aim of this study was to investigate the differences in foot kinematics between adults with and without medial knee OA during barefoot walking. METHODS Foot kinematics were measured during walking in 30 adults; 15 with medial knee OA (mean age was 67.0 with a standard deviation (SD) of 8.9 years; height was 1.66 with SD of 0.13 m; body mass was 84.2 with SD of 15.8 kg; BMI was 30.7 with SD of 6.2 kg/m(2); K-L grade 3: 5, grade 4: 10) and 15 aged and gender matched control participants with 12 motion analysis cameras using the IOR multi-segment foot model. Motion of the knee joint, hindfoot, midfoot, forefoot and hallux were compared between groups using clustered linear regression. RESULTS The knee OA group displayed reduced coronal plane range of motion of the midfoot (mean 3.8° vs. 5.4°, effect size=1.1, p=0.023), indicating reduced midfoot mobility. There was also a reduced sagittal plane range of motion at the hallux in the knee OA group compared to the control group (mean 29.6° vs. 36.3°, effect size=1.2, p=0.008). No statistically significant differences in hindfoot or forefoot motion were observed. CONCLUSIONS People with medial knee OA display altered foot function compared to healthy controls. As foot and knee function are related, it is possible that altered foot function in people with knee OA may influence the effects of footwear and insoles.