Heel pad stiffness in runners with plantar heel pain.

OBJECTIVE: To evaluate significant differences in heel pad stiffness within a cohort of runners with diagnosed plantar heel pain and to explore the clinical importance of maximum heel pad stiffness values. DESIGN: A cross-sectional design was used to quantify the heel pad stiffness of 166 runners with 33 diagnosed with plantar heel pain. BACKGROUND: Palpation is still widely used to evaluate heel pad stiffness subjectively in everyday clinical practice. However, there is limited quantifiable data pertaining to heel pad stiffness measurements in runners and those with heel pain. METHODS: A portable hand-held device measured force applied by a metal probe, and its displacement into the plantar surface of the heel pad. Non-linear modelling allowed curve coefficients b0 and b1 to be evaluated and was described by an exponential function using a non-linear regression equation. Exploratory analysis was used to describe a single-point approximation for clinical use. RESULTS: An independent t-test demonstrated a statistically significant difference between the curve coefficient b1 (p<0.05). No significant difference was found for coefficient b0 between the plantar heel pain group and the non-plantar heel pain group (p>0.05). Exploratory analysis demonstrated maximum mean stiffness of 3.22 N/mm for the non-plantar heel pain group and 2.87 N/mm for the plantar heel pain-group, an 11% mean difference. CONCLUSION: The results suggested that heel pad stiffness may be associated with plantar heel pain subjects. RELEVANCE: Heel pad stiffness measurements may give a better insight into the mechanical properties of the heel pad in subjects with plantar heel pain.

Development and validation of a self-efficacy scale for use in British patients with rheumatoid arthritis (RASE).

OBJECTIVE: Current arthritis self-efficacy scales have attracted some criticism. Therefore, the aim of this study was to develop and validate a measure of self-efficacy for use in British rheumatoid arthritis patients [Rheumatoid Arthritis Self-efficacy (RASE) scale]. METHODS: Phase I: item generation of self-management strategies by rheumatology professionals and patients to create a pilot RASE. Phase II: examination of the internal structure (n=88) using correlation coefficients and principal component analysis (PCA) to create the final RASE. Phase III: reliability in 23 patients. Phase IV: comprehension, construct validity and sensitivity to change in 48 rheumatoid arthritis patients undergoing a self-management programme, using correlation coefficients, PCA and inter-item correlation. RESULTS: Phase I: of 166 self-management items generated, 100 commonly cited items were selected for the pilot RASE. Phase II: using a correlation matrix and PCA, a 28-item RASE was created. Phase III: good 4-week reliability was seen (r=0.889, P<0.001). Phase IV: the final RASE was shown to be independent of mood, disease status and disability and weakly associated with other self-efficacy scales (r=0.313, P<0.05). The RASE was sensitive to change following an education programme (+5.167, P<0.025), and was associated with behaviour initiation (r=0.35, P<0.01). CONCLUSIONS: Careful construction means that the RASE examines beliefs in potential ability to perform tasks, rather than actual ability, performance or outcome expectancy. It shows good face validity and reliability, plus reasonable construct validity and sensitivity. Further studies are needed to support the validation of this new scale.

Introducing clinical governance in an acute trust.

The introduction of clinical governance is a major imperative for the NHS. This paper describes the initial actions taken in a large acute trust to prepare for the clinical governance process. While this description is particular to one trust, it is hoped that it offers some generalizable lessons.

Clinical economics review: gastrointestinal complications of non-steroidal anti-inflammatory drugs.

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most widely used symptomatic remedies for rheumatic disorders. Their major side-effects involve the gastrointestinal tract and, while the stomach is often the prime focus of adverse reactions, the whole gut may be involved. A number of strategies have been used to reduce both the incidence of side-effects and their economic consequences. Decreased NSAID use can be achieved both by rational prescribing and by active promotion of other, usually non-pharmacological, methods of controlling symptoms. Prescribing NSAIDs based on their cost assumes all have equal efficacy and side-effects, which is demonstrably untrue. Picking the least toxic NSAID is more logical. Most of the larger studies and meta-analyses available concentrate on older NSAIDs and risk overlooking the advantages of newer preparations which have been shown to be cost beneficial by more comprehensive economic analyses. Misoprostol prophylaxis has been the subject of a number of economic evaluations which, until recently, were based on extrapolations rather than clinical data. There are now good clinical data available which show a small but significant reduction in major side-effects at the expense of an increase in minor but unpleasant ones. Proton pump inhibitors appear to offer the same degree of gastroprotection as misoprostol, with the additional benefit of symptom relief. Economic data regarding the costs and benefits of prophylaxis with proton pump inhibitors are not yet available. There is still a need for a more comprehensive evaluation of the benefits of NSAIDs in different clinical situations to balance against the costs of adverse reactions.

Choice of NSAID and management strategy in rheumatoid arthritis and osteoarthritis. The impact on costs and outcomes in the UK.

OBJECTIVE: Although nonsteroidal anti-inflammatory drugs (NSAIDs) are an effective therapy for rheumatoid arthritis, they are associated with significant adverse effects, the management of which imposes additional costs on the healthcare system. Prescribing NSAIDs which have a lower risk of major adverse effects as the first-line NSAID for patients with rheumatoid arthritis and osteoarthritis may be expected to lead to an improvement in clinical outcomes and reduce overall treatment costs. This analysis examines data from a published randomised controlled trial of 5 NSAIDs to explore these hypotheses. DESIGN AND SETTING: Data from a clinical trial comparing 5 NSAIDs were combined with published cost data to construct 2 clinical decision models, reflecting alternative approaches to the management of major and minor adverse effects in the UK. INTERVENTIONS: The 5 NSAIDs evaluated in the analysis were nabumetone, diclofenac, ibuprofen, piroxicam and naproxen, although only the results for ibuprofen and nabumetone are reported. MAIN OUTCOME MEASURES AND RESULTS: The total cost of care per patient receiving nabumetone was estimated to be between 25 pounds sterling (Pound) and 41 Pounds more expensive than ibuprofen. In a hypothetical cohort of 100,000 patients, there were between 690 and 821 more major adverse effects using ibuprofen than nabumetone. The cost per life-year gained (LYG) from using nabumetone rather than ibuprofen ranged between 1880 Pounds and 2517 Pounds (1995 values), depending upon the management of adverse effects. CONCLUSIONS: These results indicate that: (i) prescribing the newer, currently more expensive, NSAIDs will not necessarily lead to cost savings; (ii) the management of adverse effects can have a significant impact on costs; and (iii) the additional cost may be justifiable in terms of the mortality and morbidity gains associated with the new lower-risk NSAIDs.

Ultrasonic heel pad thickness measurements: a preliminary study.

The heel pad has an important role in pain-free locomotion due to its shock-attenuation function. Various diagnostic techniques are available to measure heel pad thickness. Ultrasonic measurement of the heel pad is inexpensive, involves no ionizing radiation and is portable, making it an ideal screening technique. Measurement errors may occur between different ultrasonic techniques used to measure heel pad thickness. A new standardized ultrasonic technique was performed on 15 healthy volunteers. The ultrasonic measurements were compared with the measurement obtained from a normal non-weightbearing heel pad thickness ultrasonic assessment. The results demonstrated a significant mean difference (p < 0.001) between the two techniques. The 95% confidence interval of the heel pad thickness difference indicated values between 7.68 and 9.13 mm. These results suggest that a standardized technique reduces the variability of measurement error when using weightbearing ultrasound, allowing a more reproducible diagnostic technique for assessing heel pad function, and improving patient management.

Coincident seronegative spondarthritis: a case report.

A patient is described in whom ankylosing spondylitis (AS) and reactive arthritis (ReA) coincided. Follow-up five years later showed no progression of his AS. He demonstrates that some individuals do have the capacity to express seronegative spondarthritides in different ways, possibly dependent on the infective trigger. The lack of long term effect of the second disease is both clinically reassuring and theoretically intriguing.

Polymyalgia rheumatica, temporal arteritis and malignancy.

The use of steroid therapy in polymyalgia rheumatica and temporal arteritis is necessary and usually effective, but may mask coexisting disease. The importance of early consideration of other disorders in such patients is illustrated by three case histories.

Intra-articular and soft tissue injections: a survey of current practice.

Intra-articular and soft tissue injections are the two most frequently used procedures in rheumatological practice. A questionnaire completed by 172 consultant rheumatologists aimed to ascertain the techniques used in these procedures. The results showed a wide divergence of practice in almost every aspect of technique. Respondents were willing to undertake injections in almost any location, but differed widely regarding personal and patient preparation before injection. About one-quarter used no local anaesthetic, the majority using local anaesthetic before or with the corticosteroid. Admission overnight or as a day case for injection of weight-bearing joints was practised by 18%. Post-injection advice was extremely variable. The results suggest that there is at present no single consensus technique for intra-articular and soft tissue injections amongst British consultant rheumatologists.

Non-steroidal anti-inflammatory induced diaphragm disease of the small intestine: complexities of diagnosis and management.

A 52-yr-old lady with RA on long term NSAIDs developed an iron-deficiency anaemia and subsequently presented with subacute intestinal obstruction. After intensive investigation, a diagnosis of diaphragm disease of the small intestine was made at laparotomy. The features of diaphragm disease and the difficulties with diagnosis and management of the condition are discussed.

Changes in stiffness following short- and long-term application of standard physiotherapeutic techniques.

A computer-controlled MCP joint arthrograph was developed to measure the stiffness of finger joints objectively. This was used to study the short-term (one application) and long-term (multiple applications over 6 weeks) effects of several physiotherapeutic methods on the reduction in joint stiffness. The techniques used were hot wax baths, pulsed ultrasound alone, wax baths plus pulsed ultrasound and exercise. In the short-term (i.e. after each application) wax plus ultrasound produced a statistically significant reduction in elastic torque range (P < 0.01) and dissipated energy (P < 0.05). However, the reductions in these stiffness parameters were temporary. Long-term no significant reductions in stiffness were measured. In other words, stiffness was reduced by each therapy session, but it then increased again before the next session. Wax, ultrasound alone or exercise produced no short- or long-term effects.

The effect of exercise on ankylosing spondylitis--a preliminary study.

The Polhemus Navigation Sciences 3Space Isotrak system was used to measure the range of lumbar spinal motion of 57 patients with ankylosing spondylitis. Forty-three of these attended voluntary exercise sessions for an average of one and a half hours per week while 14 did not participate in any formal exercise groups. Exercising patients fell into two groups: those attending moderate and those attending vigorous exercise sessions. Results for exercising patients obtained immediately pre- and post- a single exercise session showed a small but significant increase in extension for the vigorous exercise group but no significant changes in any other movement for either of the groups. In a group of 44 patients (33 exercising, 11 non-exercising) who were followed-up over a 2 to 6 month period, slight loss of flexion (5.5 degrees) and lateral bend (3 degrees) was observed but there was no change in range of extension.