Gait Rehabilitation for Foot and Ankle Impairments in Early Rheumatoid Arthritis: a Feasibility Study of a New Gait Rehabilitation Programme (GREAT Strides)

BackgroundFoot impairments in early rheumatoid arthritis are common and lead to progressive deterioration of lower limb function. A gait rehabilitation programme underpinned by psychological techniques to improve adherence, may preserve gait and lower limb function. This study evaluated the feasibility of a novel gait rehabilitation intervention (GREAT Strides) and a future trial. MethodsThis was a mixed methods feasibility study with embedded qualitative components. People with early (<2 years) rheumatoid arthritis (RA) and foot pain were eligible. Intervention acceptability was evaluated using a questionnaire. Adherence was evaluated using the Exercise Adherence Rating Scale (EARS). Safety was monitored using case report forms. Participants and therapists were interviewed to explore intervention acceptability. Deductive thematic analysis was applied using the Theoretical Framework of Acceptability. For fidelity, audio recordings of interventions sessions were assessed using the Motivational Interviewing Treatment Integrity (MITI) scale. Measurement properties of four candidate primary outcomes, rates of recruitment, attrition and data completeness were evaluated.Results35 participants (68.6% female) with median age (inter-quartile range [IQR]) 60.1 [49.4-68.4] years and disease duration 9.1 [4.0-16.2] months), were recruited and 23 (65.7%) completed 12-week follow-up. Intervention acceptability was excellent; 21/23 were confident that it could help and would recommend it; 22/23 indicated it made sense to them. Adherence was good, with a median [IQR] EARS score of 17/24 [12.5-22.5]. One serious adverse event that was unrelated to the study was reported. Twelve participants’ and 9 therapists’ interviews confirmed intervention acceptability, identified perceptions of benefit, but also highlighted some barriers to completion. Mean MITI scores for relational (4.38) and technical (4.19) aspects of motivational interviewing demonstrate good fidelity. The Foot Function Index disability subscale performed best in terms of theoretical consistency and was deemed most practical. ConclusionGREAT Strides was viewed as acceptable by patients and therapists, and we observed high intervention fidelity, good patient adherence and no safety concerns. A future trial to test the additional benefit of GREAT Strides to usual care will benefit from amended eligibility criteria, refinement of the intervention and strategies to ensure higher follow-up rates. The Foot Function Index disability subscale was identified as the primary outcome.Trial registrationISRCTN14277030

Effect of Foot Orthoses in Children With Symptomatic Flexible Flatfoot Based on Ultrasonography of the Ankle Invertor and Evertor Muscles

Objective To examine the changes in the cross-sectional area (CSA) ratio of the ankle invertors and evertors following rigid foot orthosis (RFO) application in children with symptomatic flexible flatfoot and to determine the correlation between the degree of change in CSA ratio and pain-severity after RFO application.Methods We included 24 children with symptomatic flexible flatfoot without comorbidities and measured the CSAs of tibialis anterior (TA), tibialis posterior (TP), and peroneus longus (PL) using ultrasonography, resting calcaneal stance position (RCSP) angle, calcaneal pitch (CP), Meary’s angle, talonavicular coverage angle, and talocalcaneal angle using radiography, and foot function index (FFI) at baseline and 12 months after RFO application. We analyzed 48 data by measuring both feet of 24 children. The CSA ratios, the ratio of CSA of each muscle to the sum of CSA of TA, TP, and PL, were also compared. Correlations between the degree of change in FFI, each muscle’s CSA ratio, RCSP angle, and radiographic measurements were investigated.Results Following RFO application, significant increase in the PL ratio and CP and significant decrease in the RCSP angle, FFI total, pain, and disability scores were observed. The degree of change in the total score, pain, and disability score of FFI were significantly correlated with the degree of change in the PL ratio and RCSP angle.Conclusion RFOs applied to children with symptomatic flexible flatfoot might reduce the compensatory activities of the ankle invertors, thereby increasing the PL ratio, and pain decreases as the PL ratio increases.

Investigation on the Site of Coronal Deformities in Hallux Valgus

BackgroundHallux valgus (HV) is a common foot deformity that is more prevalent in females, characterised by abnormal adduction of the first metatarsal (MT) and valgus deviation of phalanx on the transverse plane. Increasing evidence indicates that HV is more than a 2D deformity but a 3D one with rotational malalignment. Pronation deformity is seen during clinical examination for HV patients, but the exact origin of this rotational deformity is still unknown. Some attribute it first tarsometatarsal (TMT) joint rotation, while others attribute it to intra-metatarsal bony torsion. In addition, the correlation between the rotational and transverse plane deformity is inconclusive. Identifying the origin of the rotational deformity will help surgeons choose the optimal surgical procedure while also enhancing our understanding of the pathophysiology of Hallux valgus.ObjectiveThis study aims to (1) develop an objective method for measuring the first MT torsion and first TMT joint rotation; (2) investigate the exact location of the coronal deformity in HV; (3) investigate the relationship between the severity of deformity on the transverse and coronal planes as well as the correlation between deformity severity and foot function/symptoms in HV.MethodsAge-matched females with and without HV were recruited at Foot and Ankle Clinic of the Department of Orthopaedics and Traumatology. Computed tomography was conducted for all subjects with additional weight-bearing dorsal-plantar X-ray examination for HV subjects. Demographic information of all subjects was recorded, and foot function was evaluated. Intra-class correlation was used to explore the relationship between deformities on different planes and the deformity severity and functional outcomes, respectively. Independent t-test was used to compare joint rotation degrees and bone torsion degrees.ResultsHallux Valgus patients had more TMT joint rotation but not MT torsion compared to normal controls. TMT joint rotation is significantly correlated with foot functions. No relationship was found between the coronal rotation and the 1,2-intermetatarsal angle (IMA) or Hallux valgus angle (HVA) on the transverse plane.ConclusionOur results indicate that coronal deformities in HV may originate from TMT joint rotation. In addition, the severity of the TMT joint coronal rotation correlates with worse foot function; thus, multi-plane assessment and examination will be important for more precise surgical correction in the future.

Is 2D SWE sufficient as clinical diagnosis in patients with plantar fasciitis?

Background The use of shear wave elastography (SWE) seems to be an important imaging method in the diagnosis of plantar fasciitis (PF). Purpose To compare patients diagnosed with PF with similar and young healthy control groups in terms of B-mode ultrasound (US) and SWE results and to evaluate the elasticity of the plantar fascia. Material and Methods A total of 140 feet of 70 participants were evaluated, including 30 patients and 40 healthy individuals as the control. Clinical, B-mode US, and SWE evaluations were performed for each patient. In addition, American Orthopedic Foot and Ankle Score (AOFAS) was calculated to evaluate pain and foot function in both groups. Results Of the patients in the PF group, 40 (88%) were women and the healthy control groups had similar sex distributions ( P = 0.23). The AOFAS score was lower in feet with PF compared to the other groups ( P < 0.001). Of 30 patients with PF, 15 (50%) had bilateral PF and 15 (50%) unilateral PF. In addition, ≥4 mm thickness measurement, which was used as a diagnostic criterion for PF as a US finding, could be shown in 11 (73.3%) patients with unilateral PF and 6 (40%) patients with bilateral PF. Conclusion In conclusion, the evaluation of the diagnosis of PF with clinical findings and regular follow-up of measurements with SWE can provide measurement results with higher sensitivity in the diagnosis of PF.

Spatiotemporal Parameters And Gait Variability In People With Psoriatic Arthritis (Psa) : A Cross-Sectional Study.

Background: Foot involvement is a major manifestation of psoriatic arthritis (PsA) and could lead to severe levels of foot pain and disability and impaired functional mobility and quality of life. Gait spatiotemporal parameters (STPs) and gait variability, used as a clinical index of gait stability, have been associated with several adverse health outcomes including risk of falling, functional decline, and mortality in a wide range of populations. Previous studies showed some alterations in STPs in people with PsA. However, gait variability and the relationships between STPs, gait variability and self-reported foot pain and disability have never been studied in this populations. Body-worn inertial measurement units (IMUs) are gaining interest in measuring gait parameters in clinical settings.Objectives: To assess STPs and gait variability in people with PsA using IMUs and, to explore their relationship with self-reported foot pain and function and to investigate the feasibility of using IMUs to discriminate patient groups based on gait speed-critical values.Methods: 21 participants with PsA (Age: 53.9 ± 8.9 yrs; median disease duration: 6 yrs) and 21 age and gender-matched healthy participants (Age 54.23 ± 9.3 yrs) were recruited. All the participants performed three 10-meter walk test trials at their comfortable speed. STPs and gait variability were recorded and calculated using six body-worn IMUs and the Mobility Lab software (APDM®). Foot pain and disability were assessed in participants with PsA using the foot function index (FFI).Results: Cadence, gait speed, stride length, and swing phase, were significantly lower, while double support was significantly higher, in the PsA group (p< 0.006). Strong correlations between STPs and the FFI total score were demonstrated (|r|> 0.57, p< 0.006). Gait variability was significantly increased in the PsA group, but it was not correlated with foot pain and function (p< 0.006). Using the IMUs three subgroups of participants with PsA with clinically meaningful differences in self-reported foot pain and disability were discriminated.Conclusion: STPs were significantly altered in participants with PsA which could be associated with self-reported foot pain and disability. Future studies are required to confirm the increased gait variability highlighted in this study and its potential underlying causes. Using IMUs in clinical settings has been useful to objectively assess foot function in people with PsA. Study registration: ClinicalTrials.gov, NCT05075343, Retrospectively registered on 29 September 2021.

The Effects of Custom-made Foot Orthoses on Foot Pain, Foot Function, Gait Function and Freeliving Walking Activities in Psoriatic Arthritis (PsA) Patients: a Pre-experimental Trial

Introduction: Foot involvement is a major concern in psoriatic arthritis (PsA) as it can lead to severe levels of foot pain and disability as well as reduced mobility and quality of life. Previous studies have shown moderate efficacy in reducing foot pain and disability in rheumatoid arthritis patients with the use of custom-made foot orthoses (CFO). However, evidence on the efficacy of CFO in PsA patients is lacking.Objectives: Explore the effects of CFO on foot function, foot and lower limb pain, gait function, and freeliving walking activities (FWA) in PsA patients.Methods: A Pre-experimental study including 20 PsA patients (mean age: 54.10 ± 9.06 y and disease duration: 11.53 ± 10.22 y), was conducted. All the participants received and wore CFO for a 7-week period. Foot and lower limb pain and foot function were measured before and after the intervention using the numerical rating scale (NRS) and the foot function index (FFI). Gait function was assessed from gait spatiotemporal parameters (STPs) extracted during a 10-meter walk test with an gait analysis system (Mobility Lab). Freeliving walking activities (step count, freeliving cadence, time spent in different ambulatory physical activities (APA)) were recorded over 7 days using accelerometer data collected from an instrumented sock worn during waking hours.Results: PsA patients reported severe baseline levels of foot pain (54.46 ± 14.58 %) and disability (46.65 ± 16.14%) on the FFI. Statistically and clinically significant improvements with large effect sizes (Cohen’s effect size > 1, p<0.005) in foot pain and foot function were observed after 7 weeks of CFO use. A significant correlation (r=-0.64, p<0.01) between CFO wear time after the adaption period and foot function on the FFI at 7 weeks was observed. However, no significant changes were demonstrated for gait STP nor for free-living walking activities after 7 weeks of CFO use.Conclusion: Results support the clinical and biomechanical plausibility of using CFO with PsA patients to reduce pain and improve foot function. Larger and controlled studies are needed to confirm these findings and a multidisciplinary approach including the prescription of exercise therapy and physiotherapy in combination with CFO could be relevant to improve STP and promote APA in PsA patients.Study registration: ClinicalTrials.gov, NCT05075343, Retrospectively registered on 29 September 2021.

Effect of a Toe-Walking Protocol in Plantar Heel Pain: A Proof of Concept

Background: Plantar heel pain (PHP) is one of most common disorders of the foot treated in primary care. It affects athletic and sedentary populations, with patient reports of activity-limiting pain and reduced quality of life. Recently, atrophy of the forefoot plantar intrinsic musculature was identified in patients with PHP. Therefore, the purpose of this study was to assess whether loading the plantar fascia strengthens the intrinsic foot musculature (IFM) and decreases symptoms in subjects with PHP Methods: A within-subjects experimental design assessed foot function, foot pain, disability, and activity limitation in 12 subjects with PHP prior to and at the end of a six-week toe-walking program. The primary outcome measure was the Foot Function Index (FFI). IFM strength (both hallux flexion and lesser toe flexion) was measured as a secondary outcome. Results: After six weeks of treatment, the mean (SD) FFI score significantly decreased from 73.2 (32.4) to 43.3 (22.8) points (p = 0.010, ES=1.1). HHD measures: Both great toe flexion and lesser toes flexion strength measures demonstrated significant force increases from 21.8N to 29.6N (+7.8N) 95%CI [1.3, 14.4] (p=0.024, ES=1.0) and from 21.4N to 28.4N (+6.6N) 95%CI [1.8, 11.4] (p=0.010, ES=0.9), respectively. Conclusion: Results suggest that toe-walking may reduce PHP symptoms and increase IFM strength. There was no identified correlation between the IFM and FFI changes. Symptom reduction may be due to a reduction in cortical inhibition rather than IFM strength changes. Findings provide foundation for future larger and more controlled studies, to further validate the effectiveness of toe-walking in reducing symptoms of PHP patients. Trial registration: Bond University Ethics Committee (BUHREC Protocol No. 1908)

Clinical Study on Different Methods of Internal Fixation for Treatment of Lisfranc Joint Injury

The Lisfranc joints are mainly used to connect the forefoot and midfoot and maintain the stability of the arch of the foot. It is an important part of the arch of the foot. If the Lisfranc joints injury is not treated in time, it will cause poor walking, pain in the back of the foot, and even deformity or disability of the forefoot. The common treatment method is to select the Kirschner wires, screws, or steel plates for incisional repositioning internal fixation surgery. In our study, we used different materials to perform fixation surgery on Lisfranc joint injury patients. We measured the joint recovery, pain condition, complications, and biomechanical indexes of different groups of patients after the operation. The results of the study showed that compared with Kirschner wire and screw internal fixation, the use of shaped arch bridge-type microsteel plate internal fixation for the treatment of metatarsotarsal joint injury patients has better foot function recovery, fewer complications, and more reliable biomechanical strength.