Non-surgical management of posterior tibial tendon dysfunction- a UK survey.

BACKGROUND: Posterior Tibial Tendon Dysfunction (PTTD) is commonly seen within musculoskeletal care. The condition's prevalence and management is poorly understood. This study aims to demonstrate current practice by multi-professional clinicians across the United Kingdom within the National Health Service. METHODS: A national (UK) cross-sectional online survey was conducted among multi-professionals who treat PTTD within their NHS practice. The survey covered assessment, management and evaluation. This was shared via social media and professional groups. RESULTS: Two hundred thirteen surveys were completed, with 153 matching the eligibility criteria. The main respondents were Physiotherapists (48%) and Podiatrists (38%). Ultrasound scanning was used most frequently when considering initial imaging (67%). Many different treatment modalities were used, but a core set of education/advice, foot orthoses, and foot specific as well as general exercise were most commonly chosen. Outcome measures routinely used were pain scale (96/269) and single leg heel raise (84/269), but patient reported outcome measures were not routinely used. The most frequent reason to escalate care was failure to manage symptoms with conservative management (106/123; 86.2%), followed by fixed deformity (10/123; 8.2%). CONCLUSIONS: This survey provides evidence on current non-surgical management for PTTD from UK NHS practice. It provides a valuable marker for clinicians to use to compare their own practice and can be used in further research as a comparator.

Person-Specific Template Matching Using a Dynamic Time Warping Step-Count Algorithm for Multiple Walking Activities.

This study aimed to develop and evaluate a new step-count algorithm, StepMatchDTWBA, for the accurate measurement of physical activity using wearable devices in both healthy and pathological populations. We conducted a study with 30 healthy volunteers wearing a wrist-worn MOX accelerometer (Maastricht Instruments, NL). The StepMatchDTWBA algorithm used dynamic time warping (DTW) barycentre averaging to create personalised templates for representative steps, accounting for individual walking variations. DTW was then used to measure the similarity between the template and accelerometer epoch. The StepMatchDTWBA algorithm had an average root-mean-square error of 2 steps for healthy gaits and 12 steps for simulated pathological gaits over a distance of about 10 m (GAITRite walkway) and one flight of stairs. It outperformed benchmark algorithms for the simulated pathological population, showcasing the potential for improved accuracy in personalised step counting for pathological populations. The StepMatchDTWBA algorithm represents a significant advancement in accurate step counting for both healthy and pathological populations. This development holds promise for creating more precise and personalised activity monitoring systems, benefiting various health and wellness applications.

A multi-professional survey of UK practice in the use of intra-articular corticosteroid injection for symptomatic first metatarsophalangeal joint osteoarthritis.

BACKGROUND: The first metatarsophalangeal joint is the most common site of osteoarthritis (OA) in the foot and ankle. Intra-articular corticosteroid injections are widely used for this condition, but little is known about their use in practice. This study explored current practice within the UK National Health Service (NHS) relating to the administration of intra-articular corticosteroids for people with painful first metatarsophalangeal joint (MTPJ) OA. METHODS: A cross-sectional survey using Qualtrics online survey platform (Qualtrics, Provo, UT, USA), distributed through professional bodies, special interest groups, and social media. RESULTS: One hundred forty-four healthcare professionals responded, including podiatrists (53/144; 39%), orthopaedic surgeons (28/144; 19%), podiatric surgeons (26/144; 17%) and physiotherapists (24/144; 16%). Half of respondents administered up to 25 corticosteroid injections per year (67/136; 49%) but some administered more than fifty (21/136; 15%). Injections were administered across the healthcare system but were most common in hospital settings (64/136; 44%) followed by community (38/136; 26%), with less delivered in primary care (11/136; 8%). Half of respondents routinely used image-guidance, either ultrasound or x-ray/fluoroscopy (65/136; 48%) although over one third used none (52/136; 38%). Imaging guidance was more common amongst medical professionals (21/31; 68%) compared to non-medical health professionals (45/105; 43%). Overall, methylprednisolone acetate was the most common corticosteroid used. Medical professionals mostly injected methylprednisolone acetate (n = 15/27; 56%) or triamcinolone acetonide (n = 11/27; 41%), whereas premixed methylprednisolone acetate with lidocaine hydrochloride was the most common preparation used by non-medical health professionals (41/85; 48%). When injecting non premixed steroid, lidocaine hydrochloride (15/35; 43%) was the most common choice of local anaesthetic for non-medical health professionals but medical professionals showed more variation between lidocaine hydrochloride (8/23; 35%) levobupivacaine hydrochloride (9/23; 39%) and bupivacaine hydrochloride (5/23; 22%). CONCLUSIONS: Multiple professional groups regularly administer intra-articular corticosteroids for symptomatic first MTPJ OA across a range of NHS healthcare settings. Overall, methylprednisolone acetate was the most commonly administered steroid and lidocaine hydrochloride the most common local anaesthetic. There was large variation in the use of imaging guidance, type and dose of steroid, local anaesthetic, and clinical pathways used in the intra-articular injection of corticosteroids for people with first MTPJ OA.

The short-term impact of non-removable offloading devices on quality of life in people with recurrent diabetic foot ulcers.

OBJECTIVE: Recurrent diabetic foot ulcers (DFUs) are associated with poor health-related quality of life and reduced mobility. Current guidelines recommend application of non-removable offloading devices (NROLDs) as they may improve the healing of DFUs, but there is a lack of information on the wider effects of wearing these devices. Few studies have examined the impact of NROLDs on holistic wellbeing or physical activity. We aimed to investigate the short-term impact of NROLDs on physical activity and DFU-related quality of life (DFU-QoL) in a small sample of community-dwelling people with recurrent DFUs. METHOD: We measured DFU-QoL and physical activity (GPAQ) in people with DFUs, recruited from a single clinic before NROLD application, and at three and six weeks after device fitting. Participants were aged from 39-81 years (mean 58.4±10.1 years) with an equal number of male and female participants. RESULTS: The study cohort comprised 18 participants, of whom 14 (78%) completed six-week questionnaires. Although there was some interim decline observed within individual domains of the DFU-QoL (financial: mean difference (MD) 16.2 (95% confidence interval (CI) 2.1, 30.2); p=0.03); non-compliance: MD 12.5 (95% CI-0.2, 25.2); p=0.05), no differences were observed over six weeks. Levels of physical activity declined over time, with over half (56%) of participants classified as having low levels of physical activity at baseline, rising to two-thirds (67%) at follow-up. CONCLUSION: Future studies should explore the longer-term holistic impact of NROLDs and develop more personalised approaches to care at the point of prescription, during and post-device use.

Current practice in the measurement and interpretation of intervention adherence in randomised controlled trials: A systematic review.

BACKGROUND: Ideally all participants in a randomised controlled trial (RCT) should fully receive their allocated intervention; however, this rarely occurs in practice. Intervention adherence affects Type II error so influences the interpretation of trial results and subsequent implementation. We aimed to describe current practice in the definition, measurement, and reporting of intervention adherence in non-pharmacological RCTs, and how this data is incorporated into a trial's interpretation and conclusions. METHODS: We conducted a systematic review of phase III RCTs published between January 2018 and June 2020 in the National Institute for Health Research Journals Library for the Health Technology Assessment, Programme Grants for Applied Research, and Public Health Research funding streams. RESULTS: Of 237 reports published, 76 met the eligibility criteria and were included. Most RCTs (n = 68, 89.5%) reported adherence, though use of terminology varied widely; nearly three quarters of these (n = 49, 72.1%) conducted a sensitivity analysis. Adherence measures varied between intervention types: behavioural change (n = 10, 43.5%), psychological therapy (n = 5, 83.3%) and physiotherapy/rehabilitation (n = 8, 66.7%) interventions predominately measured adherence based on session attendance. Whereas medical device and surgical interventions (n = 17, 73.9%) primarily record the number of participants receiving the allocated intervention, a third (n = 33, 67.3%) of studies reported a difference in findings between primary and sensitivity analyses. CONCLUSIONS: Although most trials report elements of adherence, terminology was inconsistent, and there was no systematic approach to its measurement, analyses, interpretation, or reporting. Given the importance of adherence within clinical trials, there is a pressing need for a standardised approach or framework.

Using a modified nominal group technique to develop complex interventions for a randomised controlled trial in children with symptomatic pes planus.

BACKGROUND: Children with symptomatic flat feet (pes planus) frequently present for care but there remains uncertainty about how best to manage their condition. There is considerable variation in practice between and within professions. We intend to conduct a three-arm trial to evaluate three frequently used interventions for pes planus (exercise and advice, exercise and advice plus prefabricated orthoses, and exercise and advice plus custom made orthoses). Each of these interventions are complex and required developing prior to starting the trial. This paper focusses on the development process undertaken to develop the interventions. METHODS: We used a modified Nominal Group Technique combining an electronic survey with two face-to-face meetings to achieve consensus on the final logic model and menu of options for each intervention. Using the Nominal Group Technique across consecutive meetings in combination with a questionnaire is novel, and enabled us to develop complex interventions that reflect contemporary clinical practice. RESULTS: In total 16 healthcare professionals took part in the consensus. These consisted of 11 podiatrists, two orthotists, two physiotherapists, and one orthopaedic surgeon. Both meetings endorsed the logic model with amendments to reflect the wider psychosocial impact of pes planus and its treatment, as well as the increasing use of shared decision making in practice. Short lists of options were agreed for prefabricated and custom made orthoses, structures to target in stretching and strengthening exercises, and elements of health education and advice. CONCLUSIONS: Our novel modification of the nominal group technique produced a coherent logic model and shortlist of options for each of the interventions that explicitly enable adaptability. We formed a consensus on the range of what is permissible within each intervention so that their integrity is kept intact and they can be adapted and pragmatically applied. The process of combining survey data with face-to-face meetings has ensured the interventions mirror contemporary practice and may provide a template for other trials.

Reliability of slice-encoding for metal artefact correction (SEMAC) MRI to identify prosthesis loosening in patients with painful total hip arthroplasty - a single centre, prospective, surgical validation study.

OBJECTIVES: To validate reliability of slice-encoding for metal artefact correction (SEMAC)-MRI findings in prosthesis loosening detection by comparing them to surgical outcomes (gold standard) in symptomatic patients following hip arthroplasties. To evaluate periprosthetic anatomical structures in symptomatic patients to identify an alternative cause of hip symptoms. METHODS: We prospectively followed 47 symptomatic patients (55 hips, 39 painful hips - group P and 16 control hips - group C) at our institution from 2011 to 2016. We acquired 1.5 T MRI conventional and SEMAC-MRI images for all patients. Two consultants scored MRI for osteolysis and marrow oedema zone-wise using predefined signal characteristics and settled scoring variations by consensus. We used Spearman Rank-Order Correlation for correlation analysis and used OMERACT (Outcome Measures in Rheumatology) filter pillars to validate SEMAC-MRI findings. RESULTS: Eleven patients needed revision surgery, all from group P. None from group C required revision surgery. Remaining 28 hips in the group P were managed conservatively pain completely resolved in 21 hips, eight hips had trochanteric bursitis, eight had extraarticular cause and the remaining five hips had spontaneous pain resolution. We found moderate-to-weak correlation between SEMAC-MRI findings for prosthesis loosening and revision surgery outcomes. Sensitivity, Specificity, PPV and NPV in Group P were (72.7, 64.3, 44.4, 85.7%) in T1W-SEMAC, (90.9, 46.4, 40.0, 92.9%) in STIR-SEMAC and (36.3, 78.5, 40.0, 75.8%) in PDW-SEMAC. CONCLUSION: Negative SEMAC-MRI results can effectively exclude prosthesis loosening confirmed on revision surgery and SEMAC-MRI can detect alternative cause of hip pain accurately. ADVANCES IN KNOWLEDGE: Negative SEMAC-MRI in painful THA patients can effectively exclude prosthesis loosening as a cause.

Developing a national musculoskeletal core capabilities framework for first point of contact practitioners.

OBJECTIVE: We aimed to support service transformation by developing a core capabilities framework for first contact practitioners working with people who have musculoskeletal conditions. METHODS: We conducted a modified three-round Delphi study with a multi-professional panel of 41 experts nominated through 18 national professional and patient organizations. Qualitative data from an open-ended question in round one were analysed using a thematic approach and combined with existing literature to shape a draft framework. Participants rated their agreement with each of the proposed 142 outcomes within 14 capabilities on a 10-point Likert scale in round two. The final round combined round two results with a wider online survey. RESULTS: Rounds two and three of the Delphi survey were completed by 37 and 27 participants, respectively. Ninety practitioners responded to the wider online survey. The final framework contains 105 outcomes within 14 capabilities, separated into four domains (person-centred approaches; assessment, investigation and diagnosis; condition management, intervention and prevention; and service and professional development). The median agreement for all 105 outcomes was at least nine on the 10-point Likert scale in the final round. CONCLUSION: The framework outlines the core capabilities required for practitioners working as the first point of contact for people with musculoskeletal conditions. It provides a standard structure and language across professions, with greater consistency and portability of musculoskeletal core capabilities. Agreement on each of the 105 outcomes was universally high amongst the expert panel, and the framework is now being disseminated by Health Education England, NHS England and Skills for Health.

Foot orthoses for people with rheumatoid arthritis: a survey of prescription habits among podiatrists.

BACKGROUND: Guidelines recommend foot orthoses for people with both early (< 2 years) and established rheumatoid arthritis (RA). While prefabricated foot orthoses are cheaper and can exhibit comparable effects to customised devices, the available evidence for their effectiveness is inconsistent. Little is known about what types of foot orthoses clinicians prescribe. This study describes the foot orthoses prescription habits of podiatrists for people with rheumatoid arthritis. METHODS: One hundred and eighty-three podiatrists from the United Kingdom (UK) (n = 88), Australia (n = 68) and New Zealand (n = 27) completed a self-administered, online survey regarding the types of foot orthoses prescribed in clinical practice for people with RA. This study forms part of a wider international survey exploring foot orthosis prescription habits. RESULTS: UK respondents were more likely to prescribe prefabricated orthoses for early RA (n = 47, 53%) and customised orthoses for established RA (n = 47, 53%). Respondents in Australia were more likely to prescribe customised orthoses for both early (n = 32, 47%) and established (n = 46, 68%) RA, whilst respondents in New Zealand were more likely to prescribe prefabricated orthoses for both early (n = 16, 59%) and established (n = 10, 37%) disease.Irrespective of disease stage, the use of foam impression boxes was more prevalent in the UK and New Zealand when capturing a model of the feet prior to manufacturing customised orthoses. In contrast, electronic scanning and plaster of Paris were more common in Australia. Computer aided manufacture was utilised more frequently among respondents in Australia than in the UK and New Zealand. Respondents in all three countries specified more flexible shell materials for established RA, compared to early disease. Cushioning top covers (e.g. PORON® or polyurethane) were most frequently specified in all countries for both disease stages. CONCLUSIONS: Considerable variation was seen in the self-reported foot orthoses prescription habits of respondents for people with RA. Variation between countries and disease stage was seen in type of orthoses, specific brands, manufacturing methods, and materials prescribed. The results allow podiatrists and broader health service providers to compare their practice against reported national and international patterns.

A survey of foot orthoses prescription habits amongst podiatrists in the UK, Australia and New Zealand.

BACKGROUND: Foot orthoses are frequently used but little is known about which types are used in contemporary practice. This study aimed to explore the types of foot orthoses currently used by podiatrists and the prescription variations in a range of conditions. METHODS: A web-based, cross-sectional survey was distributed through professional bodies in the United Kingdom (UK), Australia, and New Zealand. Questions focussed on foot orthosis prescription habits in relation to 26 conditions affecting the back and lower limb. RESULTS: Two hundred and sixty-four podiatrists practising in 19 different countries completed the survey; the majority practised in the UK (47%, n = 124), Australia (30%, n = 79) and New Zealand (12%, n = 32). Respondents qualified between 1968 and 2016, and 147 (56%) were female. Respondents worked in different healthcare sectors and this varied between countries: 42 (34%) respondents in the UK worked solely in the public sector, compared to 3 (4%) in Australia and 2 (6%) in New Zealand. Forty-four (35%) respondents in the UK worked solely in private practice, compared to 64 (81%) in Australia and 14 (44%) in New Zealand.UK respondents prescribed more prefabricated orthoses per week (mean 5.5 pairs) than simple insole-type devices (±2.7) and customised devices (±2.9). Similarly, respondents in New Zealand prescribed more prefabricated orthoses per week (±7.7) than simple (±1.4) and customised (±2.8) devices. In contrast, those in Australia prescribed more customised orthoses per week (±4.4) than simple (±0.8) and prefabricated (±1.9) orthoses. Differences in the types of orthoses prescribed were observed between country of practice, working sector, and the condition targeted. Generally, prefabricated orthoses were commonly prescribed for the 26 highlighted conditions in the UK and New Zealand. Australian podiatrists prescribed far fewer devices overall, but when they did prescribe, they were more likely to prescribe custom devices. Respondents in all three countries were more likely to prescribe customised orthoses for people with diabetes complicated by peripheral neuropathy than for diabetes without this complication. CONCLUSIONS: Foot orthosis prescription habits vary between countries. Prefabricated orthoses were frequently prescribed in the UK and New Zealand, and customised orthoses in Australia. Prescriptions for people with diabetes differed depending on the presence of neuropathy, despite a lack of robust evidence supporting these decisions. This study provides new insight into contemporary practice.

Preliminary concurrent validity of the Fitbit-Zip and ActiGraph activity monitors for measuring steps in people with polymyalgia rheumatica.

BACKGROUND: Activity monitors provide objective measurements of physical activity, however, the accuracy of these devices in people with polymyalgia rheumatica (PMR) is unknown. Therefore, this study aimed to obtain preliminary evidence of the accuracy of two activity monitors and explore if clinical and gait-related factors altered device accuracy in people with PMR. METHODS: The ActiGraph with low frequency extension (+LFE) and standard (-LFE) algorithms, Fitbit-Zip (waist) and Fitbit-Zip (shirt) were concurrently tested using a two-minute walk test (2MWT) and stairs test in 27 people with PMR currently treated with prednisolone. To determine accuracy, activity monitor step-count was compared to a gold-standard step-count (GSSC; calculated from video recording) using Bland-Altman plots. RESULTS: The Fitbit-Zip (waist) achieved closest agreement to the GSSC for the 2MWT (mean bias (95%CI): 10 (-3, 23); 95%LOA: -55, 74). The ActiGraph (+LFE) achieved closest agreement to the GSSC for the stairs test (mean bias (95%CI): 0 (-1, 1); 95%LOA: -5, 5). The ActiGraph (-LFE) performed poorly in both tests. All devices demonstrated reduced accuracy in participants with lower gait velocity, reduced stride length, longer double-limb support phase and greater self-reported functional impairment. CONCLUSION: Our preliminary results suggest that in controlled conditions, the Fitbit-Zip fairly accurately measures step-count during walking in people with PMR receiving treatment. However, device error was greater than data published in healthy people. The ActiGraph may not be recommended without activation of the LFE. We identified clinical and gait-related factors associated with higher levels of functional impairment that reduced device accuracy. Further work is required to evaluate the validity of the activity monitors in field conditions.

National variation in the composition of rheumatology multidisciplinary teams: a cross-sectional study.

The objective of this study is to describe the composition of multidisciplinary teams (MDT) working within rheumatology departments across the UK. All rheumatology departments in the United Kingdom (UK) were invited to participate in a national electronic survey between February 2014 and April 2015 as a part of a national audit for the management of rheumatoid and early inflammatory arthritis commissioned by Healthcare Quality Improvement Partnership. Rheumatology departments were asked to report their MDT composition; defined as a rheumatologist (consultant or specialist trainee), specialist nurse, occupational therapist physiotherapist, and podiatrist. The data were collected as Whole Time Equivalent (WTE) of each professional group at each department adjusted to 100,000 population. The data were grouped according to British Society for Rheumatology regions to study regional variations. The survey was completed by 164/167 departments (98% response rate). All departments reported an MDT comprising a rheumatologist (consultant or specialist trainee) and almost all included a specialist nurse but only 28 (17%) of the departments had MDTs comprising all the professional groups. There was a high degree of regional variation in the provision of Allied Health Professionals (physiotherapists, occupational therapists, and podiatrists) in the UK. MDT care is recommended for the management of inflammatory arthritis, but few UK rheumatology departments have a full complement of healthcare professionals within their MDT. There is a high degree of regional variation in the composition and staffing levels of the rheumatology MDT across the UK; the impact of which warrants further investigation.

Interpreting outcome following foot surgery in people with rheumatoid arthritis.

BACKGROUND: Foot surgery is common in RA but the current lack of understanding of how patients interpret outcomes inhibits evaluation of procedures in clinical and research settings. This study aimed to explore which factors are important to people with RA when they evaluate the outcome of foot and ankle surgery. METHODS AND RESULTS: Semi structured interviews with 11 RA participants who had mixed experiences of foot surgery were conducted and analysed using thematic analysis. Responses showed that while participants interpreted surgical outcome in respect to a multitude of factors, five major themes emerged: functional ability, participation, appearance of feet and footwear, surgeons' opinion, and pain. Participants interpreted levels of physical function in light of other aspects of their disease, reflecting on relative change from their preoperative state more than absolute levels of ability. Appearance was important to almost all participants: physical appearance, foot shape, and footwear were closely interlinked, yet participants saw these as distinct concepts and frequently entered into a defensive repertoire, feeling the need to justify that their perception of outcome was not about cosmesis. Surgeons' post-operative evaluation of the procedure was highly influential and made a lasting impression, irrespective of how the outcome compared to the participants' initial goals. Whilst pain was important to almost all participants, it had the greatest impact upon them when it interfered with their ability to undertake valued activities. CONCLUSIONS: People with RA interpret the outcome of foot surgery using multiple interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than anticipated. These factors can help clinicians in discussing surgical options in patients.

A qualitative study of factors impacting upon the recruitment of participants to research studies in wound care - The community nurses' perspective.

OBJECTIVE: The focus of this study was to identify the factors that impact upon the recruitment of participants to research studies in wound care from the community nurses' perspective. METHOD: A qualitative approach utilising classic grounded theory methodology was used. Semi structured interviews were used to generate data and data analysis was facilitated by using QSR International's NVivo10 qualitative data analysis software (2012). RESULTS: Eight participants consisting of community registered nursing staff of differing levels of seniority took part in the study. Four main themes emerged from the data: CONCLUSIONS: There are a number of factors in addition to the eligibility criteria that influence community nurses when identifying potential participants for wound care trials. These factors limit the recruitment pool so may affect the transferability and generalisability of research findings to the intended population. The design of future recruitment strategies and the planning of study initiation training should take these factors into account.

Videoconferencing for site initiations in clinical studies: Mixed methods evaluation of usability, acceptability, and impact on recruitment.

BACKGROUND: A critical issue for multicentre clinical studies is conducting site initiations, ensuring sites are trained in study procedures and comply with relevant governance requirements before they begin recruiting patients. How technology can support site initiations has not previously been explored. OBJECTIVE: This study sought to evaluate use of off-the-shelf web-based videoconferencing to deliver site initiations for a large national multicentre study. METHODS: Participants in the initiations, including podiatrists, diabetologists, trial coordinators, and research nurses, completed an online questionnaire based on the System Usability Scale (SUS) (N = 15). This was followed by semi-structured interviews, with a consultant diabetologist, a trial coordinator, and three research nurses, exploring perceived benefits and limitations of videoconferencing. RESULTS: The mean SUS score for the videoconferencing platform was 87.2 (SD = 13.7), suggesting a good level of usability. Interview participants perceived initiations delivered by videoconferencing as being more interactive and easier to follow than those delivered by teleconference. In comparison to face-to-face initiations, videoconferencing takes less time, easily fitting in with the work of staff at the local sites. Perceptions of impact on communication varied according to the hardware used. CONCLUSION: Off-the-shelf videoconferencing is a viable alternative to face-to-face site initiations and confers advantages over teleconferencing.

Prevalence and microbiological characteristics of clinically infected foot-ulcers in patients with rheumatoid arthritis: a retrospective exploratory study.

BACKGROUND: The prevalence of foot ulcers in patients with rheumatoid arthritis (RA) has been reported at almost 10 %. These foot ulcers often occur at multiple sites and are reoccurring, with the potential risk of infection increased due to RA diagnosis and disease modifying medications. The objective of this study was to estimate the prevalence of clinical infection in foot-ulcers of patients with RA; describe the microbiological characteristics and investigate risk factors. METHODS: Retrospective clinical data was collected for all patients attending a rheumatology foot ulcer clinic between 1st May 2012 and 1st May 2013: wound swab data was collected from those with clinical infection. RESULTS: Twenty-eight patients with RA and foot-ulcers were identified; eight of these patients had clinical infection and wound swabs taken (29 %). Of these eight patients there were equal men and women, with median age 74 years, and average disease duration 22 years. Cardiovascular disease/peripheral-vascular disease (CVD/PVD) were reported in six patients, diabetes in two patients. Six patients were treated with disease-modifying anti-rheumatic drugs (DMARDs); three were on biologic medications and two on steroids. Five wound swabs cultured skin flora, one staphylococcus aureus, one had no growth after culture; and one was rejected due to labelling error. CONCLUSION: Almost a third of people with RA and foot ulcers attending clinic over one year had clinical infection, however microbiological analysis failed to isolate pathogens in six of seven wound swabs. This may be due to inaccurate diagnosis of ulcer infection or to issues with sampling, collection, transport, analysis or reporting. There was insufficient data to relate risk of clinical infection with risk factors. Further research is required to identify the most appropriate techniques for infection diagnosis, wound sampling and processing. TRIAL REGISTRATION: Ethical approval was obtained from University of Leeds, Faculty of Medicine and Health (Reference number: SHREC/RP/349).

Diurnal variation of gait in patients with rheumatoid arthritis: The DIVIGN study.

BACKGROUND: Circadian variation of joint stiffness (morning stiffness) and its impact on functional ability are widely recognised in rheumatoid arthritis. Subsequent within-day variation of walking ability is important due to the increased availability of instrumented gait analysis. This study aimed to quantify diurnal variation of gait in patients with rheumatoid arthritis, and explore associations with disease characteristics. METHODS: Thirty one inpatients with rheumatoid arthritis walked at a self-selected speed along a GAITRite instrumented walkway 5 times during a single day. FINDINGS: Participants showed marked diurnal variation in gait, leading to a systematic variation throughout the day (F=19.56, P=<0.001). Gait velocity and stride length both increased, whereas the proportion of each gait cycle spent in stance phase or double support decreased, consistent with improving function throughout the day. Although absolute gait velocity correlated with disease characteristics, the magnitude of diurnal variation appeared to be independent of disease activity (rho=0.26, P=0.15), disease duration (rho=-0.19, P=0.324), and underlying functional ability (rho=0.09, P=0.65). INTERPRETATION: Although morning stiffness is well recognised in rheumatoid arthritis, this is the first time that its effect on gait has been quantified. Patients with rheumatoid arthritis exhibited a systematic change in walking ability throughout the day, which was independent of disease characteristics. These findings have important implications for the interpretation of existing data and the design of future studies. Repeat measures should be conducted at the same time of day to exclude the effects of diurnal variation.

Concurrent validation of activity monitors in patients with rheumatoid arthritis.

BACKGROUND: Physical activity is frequently reported in rheumatology but it is difficult to measure objectively outside the gait laboratory. A new generation of activity monitors offers this potential but it has not yet been evaluated in patients with rheumatoid arthritis. This study aimed to evaluate three types of activity monitors in patients with rheumatoid arthritis. METHODS: The Step-N-Tune, Activ4Life Pro V3.8, and the Intelligent Device for Energy Expenditure and Activity activity monitors were tested concurrently in 12 patients with rheumatoid arthritis as well as in a healthy control group of 12 volunteers. Participants walked at a self selected speed for two minutes and were filmed for later review. Temporal and spatial gait parameters were also validated against the GAITRite walkway and the total number of steps recorded by each activity monitor was compared to a gold standard derived from half speed video replays. FINDINGS: Activity monitor performance varied between devices but all showed poorer performance when used in the group with rheumatoid arthritis. Bland-Altman plots demonstrated wider 95% limits of agreement in the group with rheumatoid arthritis and a systematic decrease in agreement between activity monitors and the gold standard with decreasing functional ability. INTERPRETATION: Despite some variation between devices, all the activity monitors tested performed reasonably well in healthy young volunteers. All except the Activ4Life showed a marked decrease in performance in patients with rheumatoid arthritis, suggesting Activ4Life could be the most suitable for use in this patient group. The marked between group difference in functional ability, and systematic decrease in device performance with deteriorating gait, indicate that activity monitors require specific validation in target clinical populations.

Use of conservative and surgical foot care in an inception cohort of patients with rheumatoid arthritis.

OBJECTIVES: To describe conservative and surgical foot care in patients with RA in England and explore factors that predict the type of foot care received. METHODS: Use of podiatry and type of foot surgery were outcomes recorded in an inception cohort involving nine rheumatology centres that recruited patients with RA between 1986 and 1998 across England. Associations between patient-specific factors and service use were identified using univariate logistic regression analyses. The independence of these associations was then verified through multiple binary logistic regression modelling. RESULTS: Data were collected on 1237 patients with RA [66.9% females, mean (s.d.) age at disease onset = 54.36 (14.18) years, median DAS = 4.09 (1st quartile = 3.04, 3rd quartile = 5.26), median HAQ = 1 (0.50, 1.63)]. Interventions involving the feet in the cohort were low with only 364 (30%) out of 1218 receiving podiatry and 47 (4%) out of 1237 patients having surgery. At baseline, female gender, increasing age at onset, being RF positive and higher DAS scores were each independently associated with increased odds of seeing a podiatrist. Gender, age of onset and baseline DAS were independently associated with the odds of having foot surgery. CONCLUSIONS: Despite the known high prevalence of foot pathologies in RA, only one-third of this cohort accessed podiatry. While older females were more likely to access podiatry care and younger patients surgery, the majority of the RA population did not access any foot care.