The main goal of the project was to compare how the Achilles tendon is affected while running with traditional shoes, minimalistic shoes and barefoot. Displacement and strain were calculated both for different shoes and for different foot strike patterns. The calculations were done with a speckle tracking algorithm and displacement was calculated for three different depths in the tendon: deep layer, mid layer and superficial layer. The goal was also to conduct this analysis after a review of the algorithm used. The review of the algorithm focused on the size of the region of interest, kernel size and frequency. Literature study showed that it is more common to use a smaller kernel size, but the same shape. The region of interest was chosen depending on the size of the tendon. Displacement and strain in the Achilles tendon was calculated for seven subjects and the result did not show any difference in amount of mean deformation due to different shoe types or foot strike patterns. It was a small sample group but the result indicated a difference in peak displacement between deep and superficial layer depending on different shoe types and foot strike patterns. The difference in peak displacement between deep and superficial layer was lowest when running barefoot, larger when running with minimalistic shoes and greatest when running with traditional shoes. This result was only achieved when running with rear foot strike pattern. When running with fore foot strike pattern the difference in peak displacement between layers did not change with different conditions. In all conditions the difference in peak displacement between the layers was greater when running with rear foot strike pattern than when running with front foot strike pattern. The deep layer displaced more than the superficial layer (p<0.01) for all conditions and foot strike patterns.

Bakgrund: Forskning idag visar på bristande egenvårdsförmåga vid fotsår orsakade av diabetesneuropati. Diabetesrelaterade fotsår ökar risken för infektioner och resulterar ofta i ökad sjukhusvård och dödlighet. Sjuksköterskor spelar en central roll i att säkerställa att patienter har förmåga att utföra god egenvård och på så sätt minska risken för utveckling av fotsår och dess komplikationer. Syfte: Syftet var att identifiera faktorer som påverkar patienters egenvård vid fotsår orsakade av diabetesneuropati. Metod: Studien genomfördes som en allmän litteraturstudie med en induktiv ansats vilken baseras på tio artiklar med kvalitativ metod, två artiklar med kvantitativ metod och en med mixad metod. Artiklarnas resultat granskades och bearbetades till kategorierna: kunskapsbrist hos sjuksköterskor, kunskapsbrist hos patienter, psykiska, fysiska och sociala hinder för patienters egenvård, motivation och patientutbildning och kommunikation. Resultat: Resultatet i litteraturstudien identifierade faktorer som påverkade egenvården vid fotsår orsakade av diabetesneuropati. Bland dessa faktorer framkom en tydlig kunskapsbrist hos både sjuksköterskor och patienter när det gällde sårvård och diabetesrelaterade fotsår. Även vikten av motivation och god kommunikation mellan hälso- och sjukvården och patienter framkom. Konklusion: Genom att identifiera faktorer som påverkade patienters egenvårdsförmåga framkom det bland annat brister i patientutbildning. Praktisk vårdverksamhet behöver därför fokusera på att åtgärda utbildningsbrister för att främja god egenvård och hälsa. / Background: Research today shows a lack of self-care ability in foot ulcers caused by diabetic neuropathy. Diabetes-related foot ulcers increase the risk of infections and often lead to increased hospital care and mortality. Nurses, therefore, play a central role in ensuring that patients have ability to carry out proper self-care and reduce the risk of develop foot ulcers and their complications. Aim: The aim was to identify factors influencing patients' self-care in cases of foot ulcers caused by diabetic neuropathy. Method: The study was conducted as a general literature review with an inductive approach and is based on ten articles using qualitative methods, two articles using quantitative methods, and one using mixed methods. The results of the articles were reviewed and categorized into: lack of knowledge among nurses, lack of knowledge among patients, psychological, physical and social barriers to patient self-care, motivation and patient education and communication. Results: The results of the literature review identified factors influencing self-care in cases of foot ulcers caused by diabetic neuropathy. Among these factors, a clear lack of knowledge was evident among both nurses and patients concerning wound care and diabetes-related foot ulcers. The importance of motivation and effective communication between healthcare and patients also emerged. Conclusion: By identifying factors affecting patients' self-care ability, deficiencies in patient education, among other things, were identified. Practical healthcare practice should, therefore, focus on addressing educational gaps to promote proper self-care and health.

Yes / If a prosthetic foot creates resistance to forwards shank rotation as it deforms during loading, it will exert a braking effect on centre of mass progression. The present study determines whether the centre of mass braking effect exerted by an amputee's habitual rigid ‘ankle’ foot was reduced when they switched to using an ‘Echelon’ hydraulic ankle–foot device. Nineteen lower limb amputees (eight trans-femoral, eleven trans-tibial) walked overground using their habitual dynamic-response foot with rigid ‘ankle’ or ‘Echelon’ hydraulic ankle–foot device. Analysis determined changes in how the centre of mass was transferred onto and above the prosthetic-foot, freely chosen walking speed, and spatio-temporal parameters of gait. When using the hydraulic device both groups had a smoother/more rapid progression of the centre of pressure beneath the prosthetic hindfoot (p ≤ 0.001), and a smaller reduction in centre of mass velocity during prosthetic-stance (p < 0.001). As a result freely chosen walking speed was higher in both groups when using the device (p ≤ 0.005). In both groups stance and swing times and cadence were unaffected by foot condition whereas step length tended (p < 0.07) to increase bilaterally when using the hydraulic device. Effect size differences between foot types were comparable across groups. Use of a hydraulic ankle–foot device reduced the foot's braking effect for both amputee groups. Findings suggest that attenuation of the braking effect from the foot in early stance may be more important to prosthetic-foot function than its ability to return energy in late stance.

This research details a procedure for the systematic design of custom foot orthotics based on simulation models and their validation through experimental and clinical studies. These models may ultimately be able to replace the use of empirical tables for designing custom foot orthotics and enable optimal design thicknesses based on the body weight and activities of end-users. Similarly, they may facilitate effortless simulation of various orthotic and loading conditions, changes in material properties, and foot deformities by simply altering model parameters. Finally, these models and the corresponding results may also form the basis for subsequent design of a new generation of custom foot orthotics. Two studies were carried out, the first involving a methodical approach to development of engineering analysis models using the FEA technique. Subsequently, for model verification and validation purposes, detailed investigations were executed through experimental and clinical studies. The results were within 15% difference for the experimental studies and 26% for the clinical studies, and most of the probability values were greater than α= 0.05 accepting our null hypothesis that the FEA model data versus clinical trial data are not significantly different. The accuracy of the FEA model was further enhanced when the uniform loading condition was replaced with a more realistic pressure distribution of 70% of the weight in the heel and the rest in the front portion of the orthotic. This alteration brought the values down to within 22% difference of the clinical studies, with the P-values once again showed no significant difference between the modified FEA model and the clinical studies for most of the scenarios. The second study dealt with the development of surrogate models from FEA results, which can then be used in lieu of the computationally intensive FEA-based analysis models in the engineering design of CFO. Four techniques were studied, including the second-order polynomial response surface, Kriging, non-parametric regression and neural networking. All four techniques were found to be computationally efficient with an average of over 200% savings in time, and the Kriging technique was found to be the most accurate with an average % difference of below 0.30 for each of the loading conditions (light, medium and heavy). The two studies clearly indicate that engineering modeling, analysis and design using FEA techniques coupled with surrogate modeling methods offer a consistent, accurate and reliable alternative to empirical clinical studies. This powerful alternative simulation-based design framework can be a viable and valuable tool in the custom design of orthotics based on an individual's unique needs and foot characteristics. With these capabilities, the CFO prescriber would be able to design and develop the best-fit CFO with the optimal design characteristics for each individual customer without relying upon extensive and expensive trial and error ad hoc approaches. Such a model could also facilitate the inspection of robustness of resulting designs, as well as enable visual inspection of the impact of even small changes on the overall performance of the CFO. By adding the results from these studies to the CFO community, the prescription process may become more efficient and therefore more affordable and accessible to all populations and groups.

Bakgrund: Diabetes Mellitus är en folksjukdom och ett samlingsnamn för flera olika typer av diabetes. En vanlig komplikation vid långvarig diabetes är fotsår, men vid god egenvård kan dessa fotsår till stor del förebyggas. Syfte: Undersöka personer med diabetes erfarenheter av egenvård relaterat till fotsår. Metod: Litteraturöversikten baserades på åtta vetenskapliga artiklar med kvalitativ design. Sökningen genomfördes i databaserna PubMed och Cinahl. Artiklarna kvalitetsgranskades, analyserades och sammanställdes. Resultat: Personer med diagnosen diabetes har i vissa fall bristande egenvård i relation till fotvård och fotsår. Analysen ledde fram till två huvudkategorier och sex subkategorier. Huvudkategorierna var; Hinder till att utföra egenvård samt Vikten av god kommunikation med vårdpersonal för att främja egenvård.  Konklusion: Personer med diabetes har i många fall bristande kunskap om fotsår. Detta leder till att de i många fall har svårt att utföra en god egenvård. Personanpassad och återkommande information från sjukvården har i många fall stärkt egenvården. / Background: Diabetes Mellitus is a public disease and a collective name for several different types of diabetes. A common complication of long-term diabetes is foot ulcers, but with good self-care, these foot ulcers can largely be prevented.  Aim: Investigate people with diabetes experiences of self-care related to foot ulcers. Methods: The literature review was based on eight scientific articles with a qualitative design. The search was performed through the databases PubMed and Cinahl. The articles were quality reviewed, analyzed and compiled. Results: People diagnosed with diabetes in some cases lack self-care in relation to foot care and foot ulcers. The analysis led to two main categories and six subcategories. The main categories were Obstacles to performing self-care and The importance of good communication with healthcare professionals to promote self-care. Conclusion: People with diabetes often lack knowledge about foot ulcers. In many cases this leads to them having difficulty in performing good self-care. Personalized and recurring information from healthcare has in many cases strengthened self-care.

Bakgrund: Förekomsten av diabetes typ 2 ökar både nationellt och internationellt. Många av dessa patienter utvecklar diabeteskomplikationer i form av diabetesneuropati som är en av de vanligaste bakomliggande orsakerna till diabetesfotsår. Samarbetet kring diabetesfotsår mellan olika professioner behöver öka för att få en bättre prognos för sårläkning och således bättre livskvalitet för dessa patienter. Diabetessjuksköterskor och distriktssköterskor är involverade i vården av patienter med diabetes och diabetesfotsår men hur samarbetet mellan dessa professioner ser ut är inte klarlagt. Syfte: Syftet med denna studie är att undersöka diabetessjuksköterskans och distriktssköterskans upplevelse av samarbete vid omvårdnad av diabetesfotsår hos patienter med typ 2 diabetes samt hur ett samarbete kan förbättra vården för patienter med diabetesfotsår.   Metod:  En kvalitativ intervjustudie med deduktiv ansats valdes för att bemöta studiens syfte. Sex semi-strukturerade intervjuer genomfördes och data analyserades enligt Granheim &amp; Lundmans kvalitativa innehållsanalys. Resultat: Studien resulterade i fem olika kategorier; vikten av kommunikation, brist på rutiner, integrerat samarbete inom vården, utveckling och heterogen kompetens samt säkerhetskultur inom vården. Förbättring av samarbetet mellan diabetessjuksköterskor och distriktssköterskor kan leda till ökad kompetensen hos sjuksköterskorna samt till bättre livskvalitet för patienter med diabetesfotsår.  Slutsats: Samtliga deltagare har uttryckt vikten av ett bra samarbete och skapande av rutiner som kan leda till bättre förutsättningar för patienter med diabetesfotsår. Betydelsen av kompetensen och kunskapsutbyte var viktiga faktorer för ett välfungerande samarbete. / Background: The incidence of type 2 diabetes is increasing both nationally and internationally. Many of the patients develop diabetic complications in the form of diabetic neuropathy, which is one of the most common underlying causes of diabetic foot ulcers. Diabetes nurses and community health nurses are involved in the care of patients with diabetes and diabetic foot ulcers, but what the collaboration between these professions looks like is not clear. Objective: The purpose of this study is to investigate the diabetes nurse's and community health nurse's experience of collaboration in the care of diabetic foot ulcers in people with type 2 diabetes and how collaboration could improve care for patients with diabetic foot ulcers. Method: A qualitative interview study with an deductive approach was chosen to meet the purpose of the study. Six semi-structured interviews were conducted and the data were analyzed according to Granheim &amp; Lundman's qualitative content analysis. Results: The study results in five different categories; the importance of communication, lack of routines, integrated collaboration in healthcare, development and heterogeneous competence and safety culture in healthcare. Improving of the collaboration between different professional groups can lead to an increase in the competence of the staff and to a better quality of life for the patients with diabetic foot ulcers. Conclusion: All participants emphasized on the importance of good collaboration and the creation of routines that can lead to better conditions for patients with diabetic foot ulcers. The importance of competence and knowledge exchange were important factors for a well-functioning collaboration.

Hip-knee-ankle-foot (HKAF) prostheses are full lower limb devices for people with hip amputations. They are designed to enable individuals to regain their mobility and move freely with little restriction. HKAFs typically have high rejection rates among users, as well as gait asymmetry and increased trunk anterior-posterior lean and pelvic tilt. In this thesis, a novel integrated hip-knee (IHK) unit was designed and evaluated to address the limitations of existing solutions. This IHK combines powered hip and microprocessor controlled knee joints into one structure, with shared electronics, sensors, and batteries. The unit is also adjustable to the user leg length by a prosthetist. ISO-10328 standard mechanical testing demonstrated acceptable structural safety and rigidity. Successful functional testing involved three able-bodied participants walking with the IHK in a hip prosthesis simulator. Hip and knee joint angles and pelvic tilt angles were recorded, gait characteristics were analyzed using video recordings. Testing showed that the participants were able to walk using the IHK, and data showed that participants used different walking strategies. Points of improvement were identified for future development of the thigh unit, including completion of a synergistic gait control system, improved battery holding mechanism, and amputee user testing.

Ramp descent is a demanding task for trans-tibial amputees, due to the difficulty in controlling body weight progression over the prosthetic foot. A deeper understanding of the impact of foot function on ramp descent biomechanics is required to make recommendations for rehabilitation programs and prosthetic developments for lower-limb amputees. The thesis aim was to determine the biomechanical adaptations made by active unilateral trans-tibial amputees (TT) using a microprocessor-controlled ankle-foot prosthesis in active (MC-AF) compared to non-active mode (nonMC-AF) or elastically articulated ankle-foot device. A secondary aim was to determine the biomechanical adaptation made by able-bodied individuals when ankle motion was restricted using a custom made ankle-foot-orthosis and provide further insight into the importance of ankle dynamics when walking on ramps. Kinetic and kinematic data were recorded from nine TT’s and twenty able-bodied individuals. Able-bodied participants, ankle restriction, led to an increase in involved limb loading response knee flexion that is accompanied by the increased knee power generation during the single-limb-support phase that correlates to TTs results. TT’s use of an MC-AF reduced the ‘plantar-flexion’ resistance following foot contact allowing foot-flat to be attained more quickly. Followed by the increased ‘dorsi-flexion’ resistance which reduced the shank/pylon rotation velocity over the support foot, leading to an increase in negative work done by the prosthesis. These findings highlight the importance of having controlled ankle motion in ramp descent. Use of an MC-AF can provide TTs controlled motion for descending ramps and hence provide biomechanical benefits over using more conventional types of ankle-foot devices. / Engineering and Physical Science Research Council (EPSRC) via Doctoral Training Account (DTA) (EP/P504821/1) Chas. A. Blatchford and Sons Ltd., Basingstoke, UK provided the prosthetic hardware, prosthetist support, and facilitated the attendance of the TT participants for this study

Background and Objectives: The foot comprises of active contractile and passive connective tissue components, which help maintain stability and facilitate movement during gait. The role of age- or pathology-related degeneration and the presence of fat within muscles in foot function and pain remains unclear. The existence of fat has to date not been quantified or compared between individuals according to age, sex, side or subregion. Materials and Methods: 18 cadaveric feet (mean age 79 years) were sectioned sagittally and photographed bilaterally. Fat in the plantar muscular space of the foot (PMSF) was quantified through the previously validated manual fat quantification method, which involved observing photographs of each section and identifying regions using OsiriX. Fat volume and percentage was calculated using a modified Cavalieri’s method. Results: All feet had fat located within the PMSF, averaging 25.8% (range, 16.5–39.4%) of the total PMSF volume. The presence of fat was further confirmed with plastination and confocal microscopy. Conclusions: These findings suggest that fat within the PMSF is a consistent but highly variable finding in elderly cohorts. Fat within the foot muscles may need to be considered a norm when comparing healthy and non-healthy subjects, and for therapeutic interventions to the foot. Further work is required to understand in detail the morphological and mechanical presence of fat in the foot, and compare these findings with pathological cohorts, such as sarcopenia. Additionally, future work should investigate if fat may compensate for the degeneration of the intrinsic muscles of the foot, with implications for both the use of orthotics and pain management.

京都大学 / 新制・課程博士 / 博士(人間健康科学) / 甲第24095号 / 人健博第102号 / 新制||人健||7(附属図書館) / 京都大学大学院医学研究科人間健康科学系専攻 / (主査)教授 市橋 則明, 教授 稲富 宏之, 教授 松田 秀一 / 学位規則第4条第1項該当 / Doctor of Human Health Sciences / Kyoto University / DFAM