The extent and nature of the impact of rheumatoid arthritis (RA) in the feet from the point of view of those with the disease is unknown. Most epidemiological studies of foot involvement in RA have been based upon radiological scoring or the findings of clinicians' examination of feet in clinically based populations. This thesis aimed to explore foot involvement in RA from the perspective of people with the disease integrated with the perceptions of rheumatologists and podiatrists. Three questionnaires were developed de novo through an iterative process of integrating information gained from focus groups, illness narratives and literature reviews. Following piloting, questionnaires sent to participants enquired about symptoms in the feet, the anatomical distribution of those symptoms, and their impact on quality of life from the perspectives of 1040 people with RA, 78 podiatrists and 414 rheumatologists throughout the UK. Additionally, the availability of podiatric services and the usefulness of interventions for foot symptoms and foot function were triangulated from participants. Quantitative data were analysed using SPSS and a process of thematic analysis was used to interpret qualitative data. Results from participants indicated that symptoms due to RA were prevalent in all parts of the foot and ankle but the metatarsophalangeal and ankle joints were most commonly and severely affected. Most people with RA (79%) reported suffering recurrent, moderate or severe foot pain every day. Other symptoms (stiffness, numbness and swelling) were also common. Overall, these findings were greater than those that have been reported previously. Foot complaints were noted to have a profound effect on quality of life, with loss of mobility due to symptoms in the feet, and difficulties finding comfortable footwear, leading to loss of independence, anger, frustration and depression; findings that have not been previously reported in detail. A gap between the need for specialist foot care and receiving such care was highlighted, with a total 82% of respondents having discussed their foot symptoms with their rheumatologist. Amongst these patients 64% had been referred to a podiatrist. Clinicians' assessment practices varied widely both within and between professions. Patients reported that on average rheumatologists examined their hands every 6.2 months, whereas their feet were only examined every 16.5 months; this led some patients to feel that rheumatologists were disinterested in their foot complaints. Additionally, the type of assessment undertaken by clinicians did not fully take account of the issues people with RA were reporting. Issues that were key to patients were quality of life and the ability to participate in valued life activities. Difficulties with obtaining adequate foot health care were noted by those with the disease and clinicians alike. Symptoms in the feet in RA are common, severe and tend to be under-reported by clinicians. Involvement of the metatarsophalangeal joints and ankles is especially troublesome. Motion in these joints is vital for normal propulsive gait. Severe involvement causes reduced mobility and impedes independence with considerable consequences for social integration. Outcome measures that exclude the feet discourage foot examination and thus do not fully account for domains of importance to those with RA. Rheumatologists and podiatrists need to work more closely in order for a more patient-centred service to be developed, where a biopsychosocial approach to foot care would more fully address the needs of people with RA.

The aim of this research was to invetigate the clinical decision-making processes used in podiatry and hence to investigate if a computer expert system could be used to aid the process of clinical decision-making. This was achieved through a sequence of four empirical studies. The initial study used card sorts to investigate seven expert podiatrists’ perceptions of and attitudes toward diagnostic aids, and in particular how podiatrists viewed expert systems. The results showed that expert systems are perceived as different in kind from other diagnostic aids such as X-rays or blood tests. The second study was conducted using one expert and one novice podiatrist and used a task analysis to investigate the types of tasks and skills undertaken by a podiatrist during the diagnosis of a patient in different clinical environments. The results indicate that the work is highly schematised and involves routine tasks such as nail care and callus reduction. In clinic, podiarists perform many tasks quickly. There was little difference between the number of tasks per minute undertaken in a general clinic and the number of tasks in a specialist diabetes clinic. Considering the speed of diagnosis, it is postulated that both expert and novice podiatrists’ use of schemata, pattern matching, and tacit and implicit knowledge dominates their diagnostic activity during consultations. The third study focused on how clinical reasoning and decision-making occur during consultations with a patient. Think-aloud protocols were used to investigate the differences in the clinical reasoning process between five expert and nine novice podiatrists. The speed of diagnosis and general lack of causal assertions suggest that use of schemata and tacit knowledge dominate the diagnosis process for both experts and novices. In a general setting, the novices produced four common clinical reasoning themes. These indicate that pattern recognition is a common method of diagnosis. However, there was an increase in the number of clinical reasoning themes used by experts in a specialist setting, indicating novice—expert differences. The fourth study used laddering interviews on a mixture of twelve NHS and private podiatrists to investigate why podiatrists used certain clinical reasoning themes. A hierarchical value map was derived, showing that, at an initial response level to the laddering questions, certain values were important: the palpation of the foot, building a picture of the foot condition, and being able to use clinical reasoning frequently and immediately. The emphases on palpation and immediacy of reasoning suggest that an expert system is unlikely to serve podiatrists’ needs in clinics. This research has provided a new understanding of the clinical reasoning processes used in podiatry. A podiatrist has a very busy timeline when diagnosing a patient and predominantly uses (and values) tacit knowledge, implicit learning, and compiled skills during consultations. There is little evidence for the need or desire for an expert system in clinical podiatry practice. However, if such an expert system were to be created, then: (a) it would have to be fast and non-intrusive so it can fit into a very busy consultation timeline, (b) it would need a knowledge base that could account for diagnosis of foot and leg conditions based on pattern recognition, and (c) it might be most valuable in the form of a decision support system for professional development that included the full range of expert diagnostic themes

Thesis (PhD)--University of South Australia, 2001.

La sole plantaire, véritable interface entre le corps et le sol, joue un rôle primordial dans le contrôle de la posture bipédique. Diverses pathologies peuvent affecter le capteur podal. Elles se situent le plus souvent au niveau de la face plantaire, et sont généralement accompagnées de phénomènes algiques voir hyperalgiques. Un quart de la population présente ou présentera une pathologie au niveau des pieds. Les douleurs associées à ces pathologies podales sont souvent décrites comme invalidantes, par les patients, réduisant le périmètre de marche et associées à une cohorte de gênes fonctionnelles (démarche antalgique, douleurs sus-jacentes, anxiété, état dépressif…). La prise en charge de podologie raisonnée de ces podalgies, notamment chez la personne âgée, représente aujourd'hui un enjeu de santé publique majeur. Pour y répondre, il est tout d’abord nécessaire de mener une recherche fondamentale sur les mécanismes mis en jeu dans le contrôle de la posture bipédique, afin de proposer une prise en charge adaptée et raisonnée (« evidence based practice ») des troubles de la posture chez des personnes souffrant de douleurs plantaires.Ce préalable important et nécessaire constitue le cœur et la justification de ce travail doctoral. L’objectif était d’évaluer les effets d’une douleur plantaire induite mécaniquement sur le contrôle de la posture bipédique.Pour répondre à cet objectif général, trois études complémentaires ont été successivement conduites. La première étude visait, dans un premier temps, à évaluer les effets d’une stimulation douloureuse des soles plantaires sur le contrôle de la posture bipédique. Les deuxième et troisième études visaient à évaluer, si et dans quelle mesure, ces effets étaient modifiés en fonction des informations visuelles et sensorielles issues du segment tête-cou pour l’étude 2 et des informations sensorielles issues du segment pied-cheville pour l’étude 3.Dans leur ensemble, les conclusions de ce travail doctoral mettent en évidence l’importance des afférences nociceptives plantaires dans le contrôle de la posture bipédique. En effet, une stimulation douloureuse mécanique des soles plantaires dégrade les capacités de contrôle de la posture bipédique. Une stimulation douloureuse mécanique des soles plantaires induit également une modification de la contribution des différentes informations sensorielles (informations visuelles, informations sensorielles issues du segment tête-cou et du segment pied-cheville) mise en jeu pour contrôler la posture bipédique, soulignant ainsi les mécanismes de repondération sensorielle.Les travaux de cette thèse de doctorat constituent un préambule fondamental indispensable à l’optimisation de la prise en charge par le podologue des douleurs plantaires, et, plus largement, à l’amélioration de l’autonomie et de la qualité de vie des personnes souffrant de douleurs plantaires. Dans ce sens, diverses études cliniques visant à évaluer les effets des orthèses plantaires, sur la prise en charge des douleurs plantaires et par voie de conséquence l’amélioration et/ou le recouvrement des capacités de contrôle de la posture bipédique, sont en cours. / The plantar sole, first point of contact between the body and the ground, plays a real key role in bipedal postural control. A lot of painful pathologies can affect the feet, particularly on the plantar face. Approximately one quarter of the population suffers or will suffer from foot injuries. The pain associated with these pathologies podal are often described as disabling for patients, reducing the walking distance and associated with a cohort of functional perturbations (limp, lowback pain, anxiety, depression ...). Care of foot pain, notably in elderly people, is a very important issue in public health. In order to achieve such care, it is necessary to conduct some fundamental research about the mechanisms that are in action concerning bipedal postural control, to propose some adapted treatments (evidence based practice) to improve the posture of the patients who have foot pain.This important and necessary prerequisite is the heart and justification of this doctoral work. The aim was to evaluate the effects of experimentally induced plantar pain on the bipedal postural control.Three experiments were successively conducted. The aim of the first experiment was to evaluate the effects of experimentally induced plantar pain on the bipedal postural control. The second and third experiments were aimed to assess if these effects were modified in function of the somatosensory information from the vision, the vestibular system and the neck (Study 2) and the somatosensory information from the ankle (Study 3).The results show that an experimentally induced plantar pain degrades the capacity to maintain postural control, and modifies the contributions of the other senses (visual, vestibular, neck and ankle muscle proprioception), showing the mechanisms of somatosensory reweighting in postural control when a pain was applied.This research constitutes a fundamental and indispensable starting point to optimize the care of foot injuries by podiatrists and, more broadly, to improve the autonomy and quality of life of persons suffering from foot pain.Clinical experiments aim to address these issues.

Title: Use of orthopaedic insoles in childhood Supervisor: PhDr. Tereza Nováková, PhD. Problem definition: The importance of the longitudinal arch is one of the most discussed topics in orthopaedics. Similarly important is the indication of orthopaedic insoles for flat feet especially in children. Experts have different opinions about what age insoles should be prescribed, and if their use is beneficial. So far, a clearly defined boundary has not been established between real pathology and a flexible flat foot formed on the basis of hypermobility which is to some extent physiological in childhood. Aim: To compare the plantograms of groups of six-year-old children with diagnosed pes planus/planovalgus before and after six month (or more) use of, individually prepared, insoles. To compare the results with a group of children that did not have insoles prescribed and on this basis to judge whether there was change (improvement) that can be proven with the use of a plantogram. Method: Two groups of six-year-old subjects were formed. The experimental group: subjects with prescribed orthopaedic insoles, and the control group: subjects that were not prescribed orthopaedic insoles. Plantograms were evaluated with the help of the Chippaux-Šmiřák index method. Conclusion: The results indicate a partial...

Introduction: Lower limbs are ones of the most strained body parts to which people do not pay much attention. Conscientious care is absolutely vital for their right functioning. Main aims of the thesis: This thesis is focused on gathering the knowledge and skills in care of lower limbs with people at their adult and old age; and on describing how the care is being performed with the target group of people. The next aim is to describe the health care from the podiatry nurse´s point of view. Methodology: A qualitative research by means of half-structured interviews was chosen as the main method of the survey. People at their adult and old age from České Budějovice were interviewed, as well as a nurse working in the centre of podiatry. Results of the thesis: The research proves some level of knowledge in the field of care of lower limbs both with the adult and elderly citizens. Both these groups of people take care of their lower limbs. The results show conscientiousness with washing their feet and drying them especially in the spaces between their toes. On the one hand, the interviewed people take care of their feet by means of using lotions and by means of pedicure. However, they do not go to see specialists in pedicure. On the other hand, the results show that this kind of skin care is not very regular. The care devoted to nails seems to be problematic, it is necessary to add some information about a more appropriate way of cutting them. The results of choosing shoes; when the choice is based mainly on a fashionable look of shoes; show a bigger need of repeated and more accurate education in this field. The impacts of improperly chosen shoes, irregular care of the lower limbs and also underestimating of prophylactic medical checks were all evident on our informants´ feet. The outputs gained in practice: The intermediate results of this thesis were presented at the Students Scientific Conference. The results of the research were used as the basis for a workshop intended for people at the adult and old age. A suggested educational mental map can be used as a practical tool.

Plantar heel pain is a common disorder that can involve considerable pain. Many treatments have been suggested to manage the condition however few have been rigorously evaluated. Two treatments commonly recommended in clinical practice are adhesive taping applied to the foot and calf muscle stretching. The effectiveness of neither treatment is supported by good quality evidence. Aim: To examine the effectiveness of two short-term interventions, low-Dye taping and calf muscle stretching, for the treatment of plantar heel pain. In addition, the effect of the interventions on biomechanical variables was investigated. Design: Four studies were undertaken in the thesis. The first study in the thesis (Chapter 3) investigated the biomechanical effect of low-Dye taping on the lower limb by systematically reviewing appropriate clinical trials. Meta-analyses were undertaken where appropriate. The second study (Chapter 4) was a blinded randomised trial conducted to evaluate the effectiveness of low-Dye taping for the short-term treatment of plantar heel pain. The third study (Chapter 5) investigated the effect of calf muscle stretching on ankle joint range of motion by systematically reviewing appropriate clinical trials. Meta analyses were again undertaken where appropriate. The fourth and final study (Chapter 6) was another blinded randomised trial conducted to evaluate the effectiveness of calf muscle stretching for the short-term treatment of plantar heel pain. Setting: Both randomised trials were conducted at a university-based clinic in Sydney, Australia. Participants In the randomised trials, 184 participants who met the inclusion and exclusion criteria for plantar heel pain were recruited from the local community. In the first trial 92 participants were evaluated over a one-week period and randomly allocated to receive either low-Dye taping or a sham intervention. In the second trial 92 participants were evaluated over a two-week period and randomly allocated to receive either calf muscle stretching or a sham intervention. Outcome measures In the first systematic review, all trials that met the inclusion and exclusion criteria evaluated the effect of low-Dye taping on kinematic, kinetic and electromyographic outcomes. For the second systematic review, all trials that met the inclusion and exclusion criteria examined the effect of calf muscle stretching on the outcome of ankle joint dorsiflexion range of motion. Both randomised trials in this thesis used the Visual Analogue Scale and the Foot Health Status Questionnaire as primary outcomes. In the stretching randomised trial secondary outcomes were also assessed, namely the Foot Posture Index-6 and the Ankle Lunge Test. Results: The first systematic review found that low-Dye taping provides a small, statistically significant increase in navicular height immediately after application (weighted mean difference 5.90mm; 95% confidence interval 0.41 to 11.39; p=0.04)1 indicating a reduction in foot pronation. However, after exercise, taping had no statistically significant effect on navicular height (weighted mean difference 4.70mm; 95% confidence interval –0.61 to 10.01; p=0.08). In addition, taping had no statistically significant effect on maximum rear foot eversion (weighted mean difference –0.59°; 95% confidence interval ����2.53 to 1.35; p=0.55) or total rear foot range of motion while walking (weighted mean difference 2.3°; 95% confidence interval –0.64 to 5.24; p=0.13). The first randomised trial found that low-Dye taping had a significantly greater decrease in ‘first-step’ pain compared to a control group. The estimate of the mean difference between the groups (measured on 100mm Visual Analogue Scale) favoured the taping group (-12.3mm; 95% confidence interval -22.4 to -2.2; p=0.017). There 1 P values are provided to three decimal places except when values were generated using systematic review software, Review Manager 4.2.7, which sometimes only calculates results to two decimal places. were no differences detected in any of the other outcome measures. The taping was associated with mild to moderate short-lived adverse events that could be minimised with the use of hypoallergenic tape and careful application of the tape to reduce tightness. The second systematic review found that calf muscle stretching provides a small, statistically significant increase in ankle joint dorsiflexion. Stretching for ≤15 minutes (in a single session or accumulated over multiple sessions) provides a weighted mean difference of 2.07° (95% confidence interval 0.86 to 3.27; p(less than)0.001). 15 to 30 minutes (accumulated over multiple sessions) increased dorsiflexion by a weighted mean difference of 3.03° (95% confidence interval 0.31 to 5.75; p=0.03), and >30 minutes of stretching (accumulated over multiple sessions) increased dorsiflexion by a weighted mean difference of 2.49° (95% confidence interval 0.16 to 4.82; p=0.04) indicating no further increase in dorsiflexion is achieved by stretching for >30 minutes. The second randomised trial found that calf muscle stretching compared to a control group, had no significant effect on ‘first-step’ pain, foot pain, foot function or general foot health. Stretching was associated with mild to moderate adverse effects that were short-lived once stretching ceased. Conclusion: When used for the treatment of plantar heel pain, low-Dye taping provides a small increase in navicular height, and after one week, produces a small reduction in the ‘first-step’ pain. Calf muscle stretching increases ankle joint dorsiflexion approximately 2 to 3 degrees but has no effect on plantar heel pain after two weeks. It can therefore be concluded that low-Dye taping is effective for the short-term treatment of the ‘first-step’ pain associated with plantar heel pain, but calf muscle stretching is not effective for plantar heel pain. / Doctor of Philosophy (PhD)

Health outcomes fulfill a number of roles in the health sector. Economists, clinicians, researchers and managers use health outcomes in a range of different contexts for distinct purposes. New management approaches that use contracts as the basis for health service accountability have attempted to take health outcomes from their clinical role into a management setting. In particular, the purchasers and managers of some health services expect that service providers should demonstrate that they improve the health outcomes of their patients to justify their on-going funding. However, a number of organisations have experienced barriers to the application of the outcomes approach to health service management and there has been no systematic evaluation of the approach. Nor has there been an investigation into why purchasing organisations have difficulty introducing health outcomes into purchasing contracts. The result is that managers and purchasers continue to assign resources to the pursuit of health outcomes as an accountability tool. This thesis addresses two research questions around the use of health outcomes in community and allied health service accountability. The first is the barriers to the application of health outcomes to health services accountability. The second question examines the conditions that must be met before health outcomes can be used as an accountability tool in purchasing contracts for allied health. The research questions are addressed through the analysis of case studies that explore systematically the approach taken by two organisations, the Department of Veterans� Affairs and ACT Community Care, in their attempts to identify health outcomes that could be used in purchasing contracts for community and allied health services. The case study analysis uses a health services research approach that draws on multidisciplinary techniques including epidemiology, health services management and anthropology. The thesis describes the accountability interactions within the purchaser-provider model. Accountability is not a uniform construct. It consists of many domains, levels and interactions. In health service delivery, there are a number of different actors and a wide range of interactions for which they are accountable. Two important interactions are identified: professional accountability, which describes the accountability of the health service professional to their patient; and contractual accountability, which is the obligation of the health service provider (or providing organisation) to the purchaser through their contractual agreement. I conclude that health outcomes are not an appropriate domain of contractual accountability but they are an important component of professional accountability and I discuss the implications of these finding for theory and practice.

No description available.

The universal presence of anatomy in healthcare professions is undeniable. It is a cornerstone to each of the clinical and basic sciences. Therefore, further expansion of current anatomical knowledge and effective methods to teach anatomy is essential. In this work, the relationship of the dorsal scapular artery with the trunks of the brachial plexus is explored with the hope that information on anatomical variation will assist neurosurgeons in sparing these structures during clinical procedures. Additionally, structures involved in biventricular pacing procedures, such as the coronary sinus and Thebesian valve, are explored for their variations in both presence and presentation. Simulations of cannulations with both 7F and 8F guiding catheters were used to collect data regarding the length of travel of a catheter within the coronary sinus. This study aimed to expand current knowledge of the coronary structures that are of importance to electrophysiologists. Furthering knowledge of how best to teach anatomy to healthcare professionals was also an aim of this work. The first education study explored whether the method of instruction affected student success in a basic science course. This study also investigated the degree of knowledge mastery that healthcare professional students had achieved in gross anatomy, microanatomy and physiology during their first year physiology course. The students were assessed at the knowledge, comprehension, application and analysis levels of Bloom's taxonomy in each discipline. A pilot study explored the degree of prior knowledge in human gross anatomy that the same healthcare professional populations (medical, dental and podiatry) possessed before beginning the first year general gross anatomy course in their healthcare curriculum. The ability for these students to evaluate when they had answered a gross anatomy question correctly and when they had answered a question incorrectly (metacognition) was explored. All four studies in this work provide further insight into anatomical education in both the clinical and basic science environments. / Cell Biology