Wesley Vernon

Building research capacity in the allied health professions

This article discusses research capacity building and its relevance for health practitioners using allied health professionals (AHPs) as a case example. Allied health professionals is a term used to represent a diverse group of health workers, each with a discrete clinical focus, whose needs for research capacity building are likely to be similar to one another and to other medical and nursing professionals. The work of AHPs challenges many current research paradigms being complex and multidisciplinary in nature, often delivered in community settings and focusing on holistic outcomes. This article examines some of the current drivers in the healthcare context and highlights tensions for AHPs in developing their research base in basic science and applied health research. The authors argue for a strategic approach to research capacity building and examine the implications of current policy initiatives for AHP roles and activity in research. The importance of a sustained approach to capacity building is underscored.

Effect of Scalpel Debridement on the Pain Associated with Plantar Hyperkeratosis

Seventy-nine subjects from 14 centers in eight English National Health Service Trusts recorded their levels of preoperative and postoperative pain and perceived change in pain on 100-mm visual analog scales before and after scalpel debridement of painful plantar hyperkeratosis. A significant reduction in pain was reported following treatment, and there were highly significant differences between the preoperative and postoperative scores. There were no age- or sex-related differences in any of the preoperative, postoperative, or perceived-change scores. The objective data support the anecdotal evidence that scalpel debridement of painful plantar hyperkeratosis is immediately effective in the palliative management of such patients.

The REFORM study protocol: a cohort randomised controlled trial of a multifaceted podiatry intervention for the prevention of falls in older people.

Introduction Falls and fall-related injuries are a serious cause of morbidity and cost to society. Foot problems and inappropriate footwear may increase the risk of falls; therefore podiatric interventions may play a role in reducing falls. Two Cochrane systematic reviews identified only one study of a podiatry intervention aimed to reduce falls, which was undertaken in Australia. The REFORM trial aims to evaluate the clinical and cost-effectiveness of a multifaceted podiatry intervention in reducing falls in people aged 65 years and over in a UK and Irish setting. Methods and analysis This multicentre, cohort randomised controlled trial will recruit 2600 participants from routine podiatry clinics in the UK and Ireland to the REFORM cohort. In order to detect a 10% point reduction in falls from 50% to 40%, with 80% power 890 participants will be randomised to receive routine podiatry care and a falls prevention leaflet or routine podiatry care, a falls prevention leaflet and a multifaceted podiatry intervention. The primary outcome is rate of falls (falls/person/time) over 12 months assessed by patient self-report falls diary. Secondary self-report outcome measures include: the proportion of single and multiple fallers and time to first fall over a 12-month period; Short Falls Efficacy Scale—International; fear of falling in the past 4 weeks; Frenchay Activities Index; fracture rate; Geriatric Depression Scale; EuroQoL-five dimensional scale 3-L; health service utilisation at 6 and 12 months. A qualitative study will examine the acceptability of the package of care to participants and podiatrists. Ethics and dissemination The trial has received a favourable opinion from the East of England—Cambridge East Research Ethics Committee and Galway Research Ethics Committee. The trial results will be published in peer-reviewed journals and at conference presentations. Trial registration number Current Controlled Trials ISRCTN68240461assigned 01/07/2011.

Achieving professional status: Australian podiatrists’ perceptions

BackgroundThis paper explores the notion of professional status from the perspective of a sample of Australian podiatrists; how it is experienced, what factors are felt to affect it, and how these are considered to influence professional standing within an evolving healthcare system. Underpinning sociological theory is deployed in order to inform and contextualise the study.MethodsData were drawn from a series of in-depth semi-structured interviews (n = 21) and focus groups (n = 9) with podiatrists from across four of Australias eastern states (Queensland, New South Wales, Victoria and Australian Capital Territory), resulting in a total of 76 participants. Semi-structured interview schedules sought to explore podiatrist perspectives on a range of features related to professional status within podiatry in Australia.ResultsCentral to the retention and enhancement of status was felt to be the development of specialist roles and the maintenance of control over key task domains. Key distinctions in private and public sector environments, and in rural and urban settings, were noted and found to reflect differing contexts for status development. Marketing was considered important to image enhancement, as was the cache attached to the status of the universities providing graduate education.ConclusionPerceived determinants of professional status broadly matched those identified in the wider sociological literature, most notably credentialism, client status, content and context of work (such as specialisation) and an ideological basis for persuading audiences to acknowledge professional status. In an environment of demographic and workforce change, and the resultant policy demands for healthcare service re-design, enhanced opportunities for specialisation appear evident. Under the current model of professionalism, both role flexibility and uniqueness may prove important.

Comparison of shoe-length fit between people with and without diabetic peripheral neuropathy: a case-control study

BackgroundAmongst the many identified mechanisms leading to diabetic foot ulceration, ill-fitting footwear is one. There is anecdotal evidence that people with diabetic peripheral neuropathy wear shoes that are too small in order to increase the sensation of fit. The aim of this study was to determine whether people with diabetic sensory neuropathy wear appropriate length footwear.MethodsA case–control design was used to compare internal shoe length and foot length differences between a group of people with diabetes and peripheral sensory neuropathy and a group of people without diabetes and no peripheral sensory neuropathy. Shoe and foot length measurements were taken using a calibrated Internal Shoe Size Gauge® and a Brannock Device®, respectively.ResultsData was collected from 85 participants with diabetes and 118 participants without diabetes. The mean difference between shoe and foot length was not significantly different between the two groups. However, a significant number of participants within both groups had a shoe to foot length difference that lay outside a previously suggested 10 to 15 mm range. From the diabetic and non-diabetic groups 82% (70/85) and 66% (78/118), respectively had a foot to shoe length difference outside this same range.ConclusionsThis study shows that although there is no significant difference in shoe-length fit between participants with and without neuropathy, a significant proportion of these populations wear shoes that are either too long or too short for their foot length according to the 10 to 15 mm value used for comparison. The study has highlighted the need for standardised approaches when considering the allowance required between foot and internal shoe length and for the measurement and comparison of foot and shoe dimensions.

Cohort Randomised Controlled Trial of a Multifaceted Podiatry Intervention for the Prevention of Falls in Older People (The REFORM Trial)

Background Falls are a major cause of morbidity among older people. A multifaceted podiatry intervention may reduce the risk of falling. This study evaluated such an intervention. Design Pragmatic cohort randomised controlled trial in England and Ireland. 1010 participants were randomised (493 to the Intervention group and 517 to Usual Care) to either: a podiatry intervention, including foot and ankle exercises, foot orthoses and, if required, new footwear, and a falls prevention leaflet or usual podiatry treatment plus a falls prevention leaflet. The primary outcome was the incidence rate of self-reported falls per participant in the 12 months following randomisation. Secondary outcomes included: proportion of fallers and those reporting multiple falls, time to first fall, fear of falling, Frenchay Activities Index, Geriatric Depression Scale, foot pain, health related quality of life, and cost-effectiveness. Results In the primary analysis were 484 (98.2%) intervention and 507 (98.1%) control participants. There was a small, non statistically significant reduction in the incidence rate of falls in the intervention group (adjusted incidence rate ratio 0.88, 95% CI 0.73 to 1.05, p = 0.16). The proportion of participants experiencing a fall was lower (49.7 vs 54.9%, adjusted odds ratio 0.78, 95% CI 0.60 to 1.00, p = 0.05) as was the proportion experiencing two or more falls (27.6% vs 34.6%, adjusted odds ratio 0.69, 95% CI 0.52 to 0.90, p = 0.01). There was an increase (p = 0.02) in foot pain for the intervention group. There were no statistically significant differences in other outcomes. The intervention was more costly but marginally more beneficial in terms of health-related quality of life (mean quality adjusted life year (QALY) difference 0.0129, 95% CI -0.0050 to 0.0314) and had a 65% probability of being cost-effective at a threshold of £30,000 per QALY gained. Conclusion There was a small reduction in falls. The intervention may be cost-effective. Trial Registration ISRCTN ISRCTN68240461

The effect of frame rate on the ability of experienced gait analysts to identify characteristics of gait from closed circuit television footage

Forensic gait analysis is increasingly being used as part of criminal investigations. A major issue is the quality of the closed circuit television (CCTV) footage used, particularly the frame rate which can vary from 25 frames per second to one frame every 4s. To date, no study has investigated the effect of frame rate on forensic gait analysis. A single subject was fitted with an ankle foot orthosis and recorded walking at 25 frames per second. 3D motion data were also collected, providing an absolute assessment of the gait characteristics. The CCTV footage was then edited to produce a set of eight additional pieces of footage, at various frame rates. Practitioners with knowledge of forensic gait analysis were recruited and instructed to record their observations regarding the characteristics of the subjects gait from the footage. They were sequentially sent web links to the nine pieces of footage, lowest frame rate first, and a simple observation recording form, over a period of 8 months. A sample-based Pearson product-moment correlation analysis of the results demonstrated a significant positive relationship between frame rate and scores (r=0.868, p=0.002). The results of this study show that frame rate affects the ability of experienced practitioners to identify characteristics of gait captured on CCTV footage. Every effort should therefore be made to ensure that CCTV footage likely to be used in criminal proceedings is captured at as high a frame rate as possible.

If the shoe fits: development of an on-line tool to aid practitioner/patient discussions about ‘healthy footwear’

BackgroundA previous study highlighted the importance of footwear to individuals’ sense of their identity, demonstrating that shoes must ‘fit’ someone socially, as well as functionally. However, unhealthy shoes can have a detrimental effect on both foot health and mobility. This project utilises qualitative social science methods to enable podiatrists to understand the broader contribution of footwear to patients’ sense of themselves and from this an online toolkit was developed to aid footwear education.MethodSemi-structured interviews were conducted with six podiatrists/shoe-fitters and 13 people with foot pathologies, some of whom also completed shoe diaries. These were supplemented with some follow-up interviews and photographs of participants’ own shoes were taken to allow in-depth discussions.ResultsFour areas related to ‘fit’ were identified; practicalities, personal, purpose and pressures, all of which need to be considered when discussing changes in footwear. These were incorporated into an online toolkit which was further validated by service users and practitioners in a focus group.ConclusionThis toolkit can support podiatrists in partnership with patients to identify and address possible barriers to changing footwear towards a more suitable shoe. Enabling patients to make healthier shoe choices will help contribute to improvements in their foot health and mobility.

Clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for falls prevention in older people: a multicentre cohort randomised controlled trial (the REducing Falls with ORthoses and a Multifaceted podiatry intervention trial).

BACKGROUND Falls are a serious cause of morbidity and cost to individuals and society. Evidence suggests that foot problems and inappropriate footwear may increase the risk of falling. Podiatric interventions could help reduce falls; however, there is limited evidence regarding their clinical effectiveness and cost-effectiveness. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for preventing falls in community-dwelling older people at risk of falling, relative to usual care. DESIGN A pragmatic, multicentred, cohort randomised controlled trial with an economic evaluation and qualitative study. SETTING Nine NHS trusts in the UK and one site in Ireland. PARTICIPANTS In total, 1010 participants aged ≥ 65 years were randomised (intervention, n = 493; usual care, n = 517) via a secure, remote service. Blinding was not possible. INTERVENTIONS All participants received a falls prevention leaflet and routine care from their podiatrist and general practitioner. The intervention also consisted of footwear advice, footwear provision if required, foot orthoses and foot- and ankle-strengthening exercises. MAIN OUTCOME MEASURES The primary outcome was the incidence rate of falls per participant in the 12 months following randomisation. The secondary outcomes included the proportion of fallers and multiple fallers, time to first fall, fear of falling, fracture rate, health-related quality of life (HRQoL) and cost-effectiveness. RESULTS The primary analysis consisted of 484 (98.2%) intervention and 507 (98.1%) usual-care participants. There was a non-statistically significant reduction in the incidence rate of falls in the intervention group [adjusted incidence rate ratio 0.88, 95% confidence interval (CI) 0.73 to 1.05; p = 0.16]. The proportion of participants experiencing a fall was lower (50% vs. 55%, adjusted odds ratio 0.78, 95% CI 0.60 to 1.00; p = 0.05). No differences were observed in key secondary outcomes. No serious, unexpected and related adverse events were reported. The intervention costs £252.17 more per participant (95% CI -£69.48 to £589.38) than usual care, was marginally more beneficial in terms of HRQoL measured via the EuroQoL-5 Dimensions [mean quality-adjusted life-year (QALY) difference 0.0129, 95% CI -0.0050 to 0.0314 QALYs] and had a 65% probability of being cost-effective at the National Institute for Health and Care Excellence threshold of £30,000 per QALY gained. The intervention was generally acceptable to podiatrists and trial participants. LIMITATIONS Owing to the difficulty in calculating a sample size for a count outcome, the sample size was based on detecting a difference in the proportion of participants experiencing at least one fall, and not the primary outcome. We are therefore unable to confirm if the trial was sufficiently powered for the primary outcome. The findings are not generalisable to patients who are not receiving podiatry care. CONCLUSIONS The intervention was safe and potentially effective. Although the primary outcome measure did not reach significance, a lower fall rate was observed in the intervention group. The reduction in the proportion of older adults who experienced a fall was of borderline statistical significance. The economic evaluation suggests that the intervention could be cost-effective. FUTURE WORK Further research could examine whether or not the intervention could be delivered in group sessions, by physiotherapists, or in high-risk patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN68240461. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 24. See the NIHR Journals Library website for further project information.

The development of a tool for assessing the quality of closed circuit camera footage for use in forensic gait analysis

Gait analysis from closed circuit camera footage is now commonly used as evidence in criminal trials. The biomechanical analysis of human gait is a well established science in both clinical and laboratory settings. However, closed circuit camera footage is rarely of the quality of that taken in the more controlled clinical and laboratory environments. The less than ideal quality of much of this footage for use in gait analysis is associated with a range of issues, the combination of which can often render the footage unsuitable for use in gait analysis. The aim of this piece of work was to develop a tool for assessing the suitability of closed circuit camera footage for the purpose of forensic gait analysis. A Delphi technique was employed with a small sample of expert forensic gait analysis practitioners, to identify key quality elements of CCTV footage used in legal proceedings. Five elements of the footage were identified and then subdivided into 15 contributing sub-elements, each of which was scored using a 5-point Likert scale. A Microsoft Excel worksheet was developed to calculate automatically an overall score from the fifteen sub-element scores. Five expert witnesses experienced in using CCTV footage for gait analysis then trialled the prototype tool on current case footage. A repeatability study was also undertaken using standardized CCTV footage. The results showed the tool to be a simple and repeatable means of assessing the suitability of closed circuit camera footage for use in forensic gait analysis. The inappropriate use of poor quality footage could lead to challenges to the practice of forensic gait analysis. All parties involved in criminal proceedings must therefore understand the fitness for purpose of any footage used. The development of this tool could offer a method of achieving this goal, and help to assure the continued role of forensic gait analysis as an aid to the identification process.