"I'm More Comfortable with a Wide-Fit Shoe" The Footwear Needs and Preferences of Older Adults in Racket Sports.

BACKGROUND: Physical activity is important throughout the lifespan. Racket sports are popular with older adults and offer important social benefits. It is unknown how the physiologic changes attributable to aging affect lower limb loading during multidirectional sports and how this may influence footwear requirements. The purpose of this work was to explore the footwear needs and preferences of older adults in racket sports to inform footwear design and development. METHODS: Semistructured interviews were conducted online with 16 participants (56-92 years of age) who typically play racket sports at least once per week. Thematic analysis was used to group basic themes into organizing themes. RESULTS: The organizing themes were comfort (general comfort, pain-free, and cushioning), functionality (relating to the structure of the shoe and performance), and choice (mostly around the appearance of the shoe). Comfort was a key priority for the majority of participants, although it was often stressed that the footwear must also be supportive. Support was frequently defined in relation to preventing ankle sprains; however, when asked directly about managing injury risk, avoiding certain shots and appropriate grip were mentioned over support. More than half of participants reported needing a wide-fitting sport shoe, which limited the footwear selection available to them. CONCLUSIONS: This study provides novel insight into the footwear requirements of active older adults, which can inform the development of footwear to facilitate safe and pain-free participation in sport for all.

Gait rehabilitation for foot and ankle impairments in early rheumatoid arthritis: a feasibility study of a new gait rehabilitation programme (GREAT Strides).

BACKGROUND: Foot 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. METHODS: This 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. RESULTS: Thirty-five 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 demonstrated good fidelity. The Foot Function Index disability subscale performed best in terms of theoretical consistency and was deemed most practical. CONCLUSION: GREAT 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 for the future trial. TRIAL REGISTRATION: ISRCTN14277030.

A new integrated behavioural intervention for knee osteoarthritis: development and pilot study.

BACKGROUND: Exercise-based approaches have been a cornerstone of physiotherapy management of knee osteoarthritis for many years. However, clinical effects are considered small to modest and the need for continued adherence identified as a barrier to clinical efficacy. While exercise-based approaches focus on muscle strengthening, biomechanical research has identified that people with knee osteoarthritis over activate their muscles during functional tasks. Therefore, we aimed to create a new behavioural intervention, which integrated psychologically informed practice with biofeedback training to reduce muscle overactivity, and which was suitable for delivery by a physiotherapist. METHODS: Through literature review, we created a framework linking theory from pain science with emerging biomechanical concepts related to overactivity of the knee muscles. Using recognised behaviour change theory, we then mapped a set of intervention components which were iteratively developed through ongoing testing and consultation with patients and physiotherapists. RESULTS: The underlying framework incorporated ideas related to central sensitisation, motor responses to pain and also focused on the idea that increased knee muscle overactivity could result from postural compensation. Building on these ideas, we created an intervention with five components: making sense of pain, general relaxation, postural deconstruction, responding differently to pain and functional muscle retraining. The intervention incorporated a range of animated instructional videos to communicate concepts related to pain and biomechanical theory and also used EMG biofeedback to facilitate visualization of muscle patterns. User feedback was positive with patients describing the intervention as enabling them to "create a new normal" and to be "in control of their own treatment." Furthermore, large reductions in pain were observed from 11 patients who received a prototype version of the intervention. CONCLUSION: We have created a new intervention for knee osteoarthritis, designed to empower individuals with capability and motivation to change muscle activation patterns and beliefs associated with pain. We refer to this intervention as Cognitive Muscular Therapy. Preliminary feedback and clinical indications are positive, motivating future large-scale trials to understand potential efficacy. It is possible that this new approach could bring about improvements in the pain associated with knee osteoarthritis without the need for continued adherence to muscle strengthening programmes. TRIAL REGISTRATION: ISRCTN51913166 (Registered 24-02-2020, Retrospectively registered).

The "price-tag" of foot health in infancy and early childhood: a cross sectional survey of UK parents.

Children's feet are complex structures and strategies for supporting good foot health throughout childhood can be challenging. Greater awareness of the contemporary factors influencing decisions, such as footwear purchases, is needed to inform health narratives which are more closely aligned to parents' attitude and behaviours. The aim of this study was to explore parent's knowledge of children's foot health, understand the common foot health concerns and experiences with footcare services. A purposeful sampling approach was used to recruit parents of children aged 5 years and under. Participants completed a self-administered, online survey which consisted of 39 questions across six sections: (1) Participant demographics; (2) Developmental events (milestones such as crawling and walking); (3) Foot health concerns; (4) Developmental aids (products such as baby bouncers and baby walkers); (5) Footwear; and (6) Foot health information. Both adaptive and mandatory questions were used. Descriptive statistics were used to summarise closed-ended questions, and a summative content analysis was adopted to draw inferences from the text data. Two-hundred thirty-nine parents completed the survey, and this represented female participants (n = 213) aged between the ages 34-42 (n = 126) or 25-34 (n = 83) years of age. The survey generated responses from a wide geographical spread across the UK, but the majority of these were from the North West of England (n = 75) and South East of England (n = 46). Four main themes were drawn from the content analysis: (1) foot health concerns and seeking advice; (2) information and advice; (3) how parents support infant milestone events; and (4) footwear.Conclusion: This work provides insight into parents' perspective on the broad topics of children's foot health, identifying common experiences and concerns about their children's foot health and the factors which influence decision making. Understanding more about these issues will help health professionals support parents during infancy and early years. What is Known: • Maintaining good foot health throughout childhood is important and many factors influence decision making. • There is little understanding about how parents care for their children feet and their understanding of good foot health practices and services. What is New: • Insight into the common factors which influence parents' approaches to supporting early development and the typical concerns that parents encountered about their children's overall foot health and footwear. • Identifies areas of children's foot health for health professionals to target when developing information sources for parents.

A toolkit for prosthetists and orthotists to facilitate progress in professional communication over the next 50 years.

BACKGROUND: In this celebratory issue of Prosthetics and Orthotics International, we review professional communication skills in the field of prosthetics and orthotics. OBJECTIVE: We aim to reflect on communication skills in the past 50 years, to discuss developments in the coming 50 years, and to create a toolkit and research agenda to facilitate progress in professional communication in the next 50 years. RESULTS: Despite being a key area in prosthetics and orthotics training programmes, we found no studies on professional communication with an experimental design published in Prosthetics and Orthotics International. As an alternative, we provide clinical reflections on the changes in professional communication in the past 50 years, and we discuss questionnaire-based and qualitative studies that provide evidence for the importance of communication in pedorthic footwear provision. In the coming 50 years, professional communication in the field of prosthetics and orthotics may be impacted by aging populations, global mobility, information technology, technological advances and emphasis on prevention. We discuss each of these topics. To facilitate progress in professional communication, we have created a toolkit with resources for prosthetics and orthotics professionals, prosthetics and orthotics students and other interested professionals. CONCLUSIONS: We hope this toolkit will inspire others to use, extend and implement it in their daily practice. As a research agenda, we strongly recommend undertaking research on interventions to improve professional communication and to study its effect on clinically meaningful outcomes.

Development and evaluation of a dual density insole for people standing for long periods of time at work.

BACKGROUND: Appropriate footwear is important for those who stand for prolonged periods of time at work, enabling them to remain comfortable, healthy and safe. Preferences for different footwear cushioning or hardness are often person specific and one shoe or insole will not be the choice for all. The aim of this study was to develop a range of insole options to maintain comfort during long periods of standing at work and test insole material preferences in the workplace. METHODS: The study consisted of two parts. Part one evaluated 9 insoles of the same geometry that varied in hardness under 2 different plantar regions (n = 34). Insole preference, plantar pressure and selected anthropometric foot measures were taken. Three insole designs based on the most preferred options were identified from this part. In part two, these three insoles were evaluated with 22 workers immediately after trying them on (1 min) and after a working day. Foot anthropometric measures and subjective questions concerning material hardness preferences and self-reported foot characteristics were used to investigate whether either had a relationship with insole preference. RESULTS: Part one found insole preference predominantly varied according to material hardness under the medial arch rather than the heel/forefoot. Softer material under the heel and forefoot was associated with a reduction in peak pressures in these regions (p < 0.05). The most preferred insole had lower pressures under the hallux and first metatarsal phalangeal joint, and greater pressures and contact area under the medial midfoot (p < 0.05) compared to the least preferred insole. Height and foot anthropometrics were related to insole preference. In part two, under real world conditions, insole preference changed for 65% of participants between the immediate assessment (1 min) and after a whole workday, with dorsum height related to the latter (p < 0.05). Subjective questions for self-assessed arch height and footwear feel identified 66.7% of the insole preferences after 1 day at work, compared to 36% using immediate assessment of insole preference. CONCLUSION: Preference for material hardness varies underneath the medial arch of the foot and is time dependent. Simple foot measures and questions about comfort can guide selection of preferred insoles.

Steps towards evidence-based foot-care for children: Behaviour and opinions of health professionals.

Allied health professionals (AHPs) working with children need the appropriate knowledge, skills and experiences to provide high-quality care. This includes using research to drive improvements in care and ensuring that knowledge and practices are consistent and build upon the best available evidence. The aim of this work was to understand more about the shared behaviours and opinions of health professionals supporting children's foot health care; how they find information that is both relevant to their clinical practice as well as informing the advice they share. A qualitative design using semi-structured, one-to-one, telephone interviews with AHPs was adopted. Thematic analysis was used to generate meaning, identify patterns and develop themes from the data. Eight interviews were conducted with physiotherapists, podiatrists and orthotists. Five themes were identified relating to health professionals: (a) Engaging with research; (b) Power of experience; (c) Influence of children's footwear companies; (d). Dr Google - the new expert and (e) Referral pathways for children's foot care. The findings indicate that the AHPs adopted a number of strategies to develop and inform their own professional knowledge and clinical practice. There could be barriers to accessing information, particularly in areas where there is limited understanding or gaps in research. The availability of online foot health information was inconsistent and could impact on how AHPs were able to engage with parents during consultations.

Exploring occupational standing activities using accelerometer-based activity monitoring.

Prolonged standing at work is required by an estimated 60% of the employed population and is associated with a high prevalence of musculoskeletal disorders. 'Standing' is expected to encompass a range of activities of varying intensity. This study aimed to define a range of 'standing' work-based activities; and objectively explore differences between 'standing' occupations. The following movements were defined using a triaxial accelerometer (ActivPAL) through recordings of known movements (n = 11): static standing, weight-shifting, shuffling, walking and sitting. Movements over a working day were defined for chefs (n = 10), veterinary surgeons (n = 7) and office workers (n = 9). Despite veterinary surgeons and chefs spending a similar time in an upright posture, veterinary surgeons spent 62% of this time standing statically whereas chefs split their time between all the movements. Overall, this study provides the first attempt to define 'standing' activities, allowing the differentiation of activities between occupations spending similar periods of time upright. Practitioner Summary: This study identified a range of work-based 'standing' activities of varying intensity. Differences in activity were recorded between two occupations spending a similar time in an upright posture (veterinary surgeons and chefs). A broader definition of standing activities could be important when considering factors related to musculoskeletal disorders at work.

A qualitative study of the experiences and perceptions of adults with chronic musculoskeletal conditions following a 12-week Pilates exercise programme.

INTRODUCTION: The aim of the present study was to explore the experiences and perceptions of adult patients with chronic musculoskeletal conditions following a Pilates exercise programme. A qualitative approach was taken to both data collection and analysis, with alignment to the philosophy of interpretive phenomenology. Participants included 15 women and seven men with a range of chronic musculoskeletal conditions, including nonspecific low back pain, peripheral joint osteoarthritis and a range of postsurgical conditions. The age range was from 36 years to 83 years, and the mean age was 57 years (standard deviation 14.1 years). METHODS: Data were collected via digital recordings of four focus groups in three North-West of England physiotherapy clinics. The data were transcribed verbatim and then analysed using a thematic framework. Data were verified by a researcher and randomly selected participants, and agreement was achieved between all parties. RESULTS: The results were organized into five main themes: physical improvements; Pilates promotes an active lifestyle: improved performance at work and hobbies; psychosocial benefits and improved confidence; increased autonomy in managing their own condition; and motivation to continue with exercise. CONCLUSION: The study was the first to investigate individual perceptions of the impact of Pilates on the daily lives of people with chronic conditions. The Pilates-based exercise programme enabled the participants to function better and manage their condition more effectively and independently. Further to previous work, the study revealed psychological and social benefits which increase motivation to adhere to the programme and promote a healthier lifestyle.

An explorative qualitative study to determine the footwear needs of workers in standing environments.

BACKGROUND: Many work places require standing for prolonged periods of time and are potentially damaging to health, with links to musculoskeletal disorders and acute trauma from workplace accidents. Footwear provides the only interaction between the body and the ground and therefore a potential means to impact musculoskeletal disorders. However, there is very limited research into the necessary design and development of footwear based on both the physical environmental constraints and the personal preference of the workers. Therefore, the purpose of this study was to explore workers needs for footwear in the 'standing' workplace in relation to MSD, symptoms, comfort and design. METHOD: Semi-structured interviews were conducted with participants from demanding work environments that require standing for high proportions of the working day. Thematic analysis was used to analyse the results and gain an exploratory understanding into the footwear needs of these workers. RESULTS: Interviews revealed the environmental demands and a very high percentage of musculoskeletal disorders, including day to day discomfort and chronic problems. It was identified that when designing work footwear for standing environments, the functionality of the shoe for the environment must be addressed, the sensations and symptoms of the workers taken into account to encourage adherence and the decision influencers should be met to encourage initial footwear choice. Meeting all these criteria could encourage the use of footwear with the correct safety features and comfort. Development of the correct footwear and increased education regarding foot health and footwear choice could help to reduce or improve the effect of the high number of musculoskeletal disorders repeatedly recorded in jobs that require prolonged periods of standing. CONCLUSION: This study provides a unique insight into the footwear needs of some workers in environments that require prolonged standing. This user based enquiry has provided information which is important to workplace footwear design.

A survey of people with foot problems related to rheumatoid arthritis and their educational needs.

BACKGROUND: Up to 50% of people with rheumatoid arthritis (RA) have foot symptoms at diagnosis, hence early foot health intervention is recommended and this should include patient education. This study identifies, for the first time, the foot health education (FHE) needs of people with RA. METHODS: An online survey of people with RA (n = 543) captured quantitative data in relation to the aims, methods of delivery, content, timing and accessibility of FHE. RESULTS: The majority concurred about the aims of FHE. Verbal delivery and websites were the most common methods. Written and verbal FHE were perceived to be the most effective methods. The point of diagnosis was the preferred time to receive it. Lack of access to FHE included minimal focus on foot health during consultations by both health practitioners and patients with RA. Participant gender, age, disease duration and living situation had a statistically significant influence on the results. CONCLUSION: Foot health education is rarely considered within the medical consultation. There is a lack of patient and/or health professional awareness of this need with a detrimental impact on foot health. Patients require health professionals to identify their foot education health needs. Tailored foot health education should begin at initial diagnosis.

A narrative review of musculoskeletal problems of the lower extremity and back associated with the interface between occupational tasks, feet, footwear and flooring.

At least 50% of workers are exposed to the risk of musculoskeletal disorders (MSD) due to spending prolonged hours standing at work. There is a lack of information regarding issues with the feet, solutions to the problem, and links between MSD, feet, footwear and flooring. The present article provides a narrative review of the research in this area, based on 31 papers. Workers who stand for large proportions of the working day had a level of MSD considerably greater than a normal population. Muscle co-activation, blood pooling, muscle fatigue and individual characteristics are all associated with MSD. Altering flooring provided mixed results, while footwear appeared to have the potential to affect MSD, although the dearth of literature limited the conclusions that could be drawn. Despite their inextricable link, literature regarding the relationship between occupational tasks, MSD, footwear and flooring remains limited and future studies will benefit from rigorously designed protocols.

Foot health education provision for people with rheumatoid arthritis-an online survey of UK podiatrists' perceptions.

BACKGROUND: Patient education supports general disease self-management and in relation to foot problems, it is recommended as a key intervention for people with rheumatoid arthritis (RA). Further, it is known what the foot health educational (FHE) needs are in relation to their experiences of foot problems. Podiatrists are the key health professionals who provide the management of RA-related foot pathology and this includes the delivery of FHE. However, we do not know what is currently provided and what podiatrists' perceptions are of this intervention. It is possible that there is a difference between what is provided and what patients need in order to maximise their foot health benefits and hence this may contribute to the persistence of foot problems and symptoms. This study primarily aims to define what UK podiatrists' perceptions of FHE are in relation to; what is delivered, how it is delivered, and the timing of its delivery, in the context of its' accessibility. The secondary aim is to identify any influence of the participants' gender, age and duration of professional qualification on their responses. METHOD: An online survey of UK HCPC registered podiatrists was used to capture quantitative data in relation to the perceived; aims, content, methods and effectiveness, timing and barriers to FHE provision to people with RA. Data was analysed to assess significant associations between the participant responses and their gender, age and duration of professional qualification. Free text comments were analysed using thematic analysis. RESULTS: 43 podiatrists across the UK completed the survey. The majority of participants stated that, they provided FHE and agreed with its overall aims. The most common methods of delivery that were perceived to be most effective were: verbal, written and website based information. The best times at which to deliver FHE were thought to be at the point of diagnosis of RA and at any available opportunity of health care delivery. The majority of participants thought they had enough knowledge and access to information resources to effectively deliver FHE, but half of the participants felt that consultation duration limited their ability to do so. Gender and duration of professional qualification influenced participants' perceptions of FHE. CONCLUSION: The importance and content of FHE for people with RA has been defined, but time limitations are seen to restrict its delivery. The development of an education needs analysis tool to facilitate efficient identification of patients FHE needs could enable timely and tailored delivery of FHE to people with RA.

An exploratory phenomenological study exploring the experiences of people with systemic disease who have undergone lower limb amputation and its impact on their psychological well-being.

BACKGROUND: Amputation is a life-changing event accompanied by challenges for the affected person with time-dependent depression often used to quantify its level of impact on their psychological well-being. There are varied factors that contribute to this and its persistence. The aim of this study was to explore the experiences over time of people with diabetes and/or peripheral vascular disease following an amputation and the impact on their psychological well-being. OBJECTIVES: To develop an understanding of the experience of living with an amputation and a chronic condition in order to help clinicians identify those in need of counselling support. STUDY DESIGN: A qualitative study utilising an iterative approach in line with the philosophy of interpretive phenomenology. METHODS: Six participants who had experienced a lower limb amputation associated with peripheral vascular disease/diabetes were interviewed on two occasions (baseline and 4 months). An interpretative phenomenological approach was utilised for both data collection and analysis. RESULTS: For these participants, amputation was part of the chronology of their chronic disease. It was the individual's variable experience of health which impacted their psychological well-being rather than the length of time since amputation. CONCLUSIONS: The multivariable experience of amputation means that individually tailored counselling/psychological support is recommended. CLINICAL RELEVANCE: An understanding of how the experience of living with an amputation and a chronic condition may change over time will help clinicians to identify the ongoing need for counselling support.

Foot Health Education for People with Rheumatoid Arthritis: ' . A Game of Chance ' - A Survey of Patients' Experiences.

OBJECTIVE: Up to 90% of people with rheumatoid arthritis (RA) experience foot problems leading to reduced function, mobility, quality of life and social participation, and impacts on body image, but these can be improved with general foot care, orthoses, footwear and patient education. Foot health patient education is lacking, so the aim of the present study was to identify the foot health educational needs of people with RA in relation to its content, timing, mode of delivery and the perceived barriers to its provision. METHODS: People with RA completed an online survey and provided free-text comments for thematic analysis. RESULTS: A total of 249 people completed the free-text section of the survey. Five main themes emerged: 'Forgotten feet'; 'Too little, too late'; 'Lacks and gaps'; 'I am my feet' and 'Game of chance'. CONCLUSION: Foot pathology in people with RA has a bio-psychosocial impact on their lives. Foot health and related information appears to be considered rarely within the medical consultation. Access to foot health information and services is limited owing to a lack of patient and/or health professional awareness, with a detrimental impact on the prognosis of their foot health. The importance of foot health in people with RA should be reinforced for patients and health professionals alike. Opportunities to discuss foot health within the medical consultation should be provided regularly. Copyright © 2015 John Wiley & Sons, Ltd.

An action research approach to facilitating the adoption of a foot health assessment tool in India.

BACKGROUND: India has a diabetes population that is growing and alongside this, the incidence of limb threatening foot problems is increasing. Foot health care provision does not yet meet this demand. In one locality in India, clinicians had an unstructured approach to foot health assessments resulting in poor adoption of evidence based guidelines from the West and a persistence of serious foot complications. There was the perception that existing assessment tools did not take into account the local cultural, organizational and professional needs and there was a lack of ownership of any potential solution to the problem. Therefore, the aim of this work was to facilitate the ownership and development of a foot health assessment tool for use in the Indian context. In order to achieve this an action research approach was chosen. METHODS: Participants were facilitated through the action and implementation phases of the action research cycle by the researchers. The action phase included generating a list of potential items for inclusion in the tool from a review of the literature to provide an evidence based foundation for the foot health assessment tool. A modified Delphi method was used to further refine the contents of the tool. Members of the Delphi Panel (n = 8) were experts in their field of medicine and experts in delivering health care within services in India. RESULTS: The outcome of the study was the adoption of a locally developed foot health assessment tool (Salford Indian Foot Health Assessment Tool, SIFT). It contains thirteen sections, which reflect the risk factors identified for assessing foot health agreed by the participants to fit the Indian context. The SIFT is supported with evidence based guidelines from the West and a training program was delivered by the researchers in order to support its implementation into clinical practice. CONCLUSION: An action research approach has facilitated the development and implementation of a locally created and owned foot health assessment tool. This in turn has resulted in the integration of evidence-based guidelines from the West with consideration to local cultural, organizational and professional needs and ultimately the needs of their patients. Further work is underway evaluating the outcomes of the SIFT in practice.

The assessment and management of diabetes related lower limb problems in India-an action research approach to integrating best practice.

BACKGROUND: In this article the authors explore the current issues and barriers related to achieving successful outcomes to diabetic foot complications in India. This was achieved by engaging clinicians in taking ownership of the problems and facilitating them in the identification of solutions to action change in clinical practice. METHODS: This was accomplished through facilitating participants in this study via a process of problem identification and planning, the first phases of an action research cycle approach. The methods of data collection were focus groups, observations and individual conversations. The data were analysed using a thematic framework. RESULTS: Based on the practitioner's experiences and opinions, key themes were identified. These themes had the potential to inform the changes needed in clinical practice, to overcome barriers and embed ownership of the solutions. Five themes were identified highlighting: concerns over a fragmented service; local recognition of need; lack of standardised care pathways; lack of structured assessment and an absence of annual foot screening. Combined, the issues identified were thought to be important in preventing timely assessment and management of foot problems. CONCLUSION: It was unanimously agreed that a formalised process of foot assessment should be developed and implemented as part of the subsequent phases of the action research process, which the authors intended to take forward and report in a further paper. The aim of which is to guide triage, education, care pathways, audit and evaluation of outcomes. Facilitation of the clinicians in developing a program and screening tool to implement and teach these skills to others could be an important step in reducing the number of high-risk cases that are often resulting in the amputation of limbs.

Guidelines for the management of people with foot health problems related to rheumatoid arthritis: a survey of their use in podiatry practice.

BACKGROUND: In the last decade there has been a significant expansion in the body of knowledge on the effects of rheumatoid arthritis (RA) on the foot and the management of these problems. Aligned with this has been the development of specialist clinical roles for podiatrists. However, despite being recommended by national guidelines, specialist podiatrists are scarce. In order to inform non-specialist podiatrists of the appropriate interventions for these foot problems, management guidelines have been developed and disseminated by a group of specialist podiatrists. The aim of this survey was to investigate the use of these guidelines in clinical practice. METHOD: Following ethical approval an online questionnaire survey was carried out. The questions were formulated from a focus group and comprised fixed response and open response questions. The survey underwent cognitive testing with two podiatrists before being finalised. An inductive approach using thematic analysis was used with the qualitative data. RESULTS: 245 questionnaires were completed (128-non-specialist working in the private sector, 101 non-specialists working in the NHS and 16 specialist podiatrists). Overall, 97% of the non-specialists (n = 222) had not heard of the guidelines. The non-specialists identified other influences on their management of people with RA, such as their undergraduate training and professional body branch meetings. Three main themes emerged from the qualitative data: (i) the benefits of the foot health management guidelines, (ii) the barriers to the use of guidelines generally and (iii) the features of useable clinical guidelines. CONCLUSIONS: This study has revealed some crucial information about podiatrists' level of engagement with the foot health management guidelines and the use of guidelines in general. Specifically, the non-specialist podiatrists were less likely to use the foot health management guidelines than the specialist podiatrists. The positive aspects were that for the specialist practitioners, the guidelines helped them to identify their professional development needs and for the few non-specialists that did use them, they enabled appropriate referral to the rheumatology team for foot health management. The barriers to their use included a lack of understanding of the risk associated with managing people with RA and that guidelines can be too long and detailed for use in clinical practice. Suggestions are made for improving the implementation of foot health guidelines.

Foot orthoses for the management of low back pain: a qualitative approach capturing the patient's perspective.

BACKGROUND: The onset of non specific low back pain is associated with heavy lifting, age, female gender, and poor general health, with psychological factors being predictors of it becoming chronic. Additionally, it is thought that altered lower limb biomechanics are a contributory factor, with foot orthoses increasingly being considered as an appropriate intervention by physiotherapists and podiatrists. However, research into the effect of foot orthoses is inconclusive, primarily focusing on the biomechanical effect and not the symptomatic relief from the patient's perspective. The aim of this study was to explore the breadth of patients' experiences of being provided with foot orthoses and to evaluate any changes in their back pain following this experience. METHOD: Following ethical approval, participants (n = 25) with non-specific low back pain associated with altered lower limb biomechanics were provided with customised foot orthoses. At 16 weeks after being provided with the foot orthoses, conversational style interviews were carried out with each patient. An interpretivistic phenomenological approach was adopted for the data collection and analysis. RESULTS: For these participants, foot orthoses appeared to be effective. However, the main influence on this outcome was the consultation process and a patient focussed approach. The consultation was an opportunity for fostering mutual understanding, with verbal and visual explanation reassuring the patient and this influenced the patient's beliefs, their engagement with the foot orthoses (physical) and their experience of low back pain (psychological). CONCLUSION: Clinicians need to adopt 'psychologically informed practice' in relation to the provision of foot orthoses. Likewise, researchers should consider all the influencing factors found in this study, both in relation to their study protocol and the outcomes they plan to measure.