Introduction: Stump healing is essential in patients with a lower limb amputation in order for them to mobilize again. Little research has been being done on factors affecting stump healing. The aim of this paper is to explore the effect of haematological makers as well as patient characteristics on stump healing after patients have undergone an amputation procedure. In addition, a practical model regarding factors that affect stump healing was developed. Methods: Patients who underwent a major lower limb amputation (above knee and below knee) at the Royal Infirmary of Edinburgh from the period of 2006 to 2009 were included in this study. A prognostic model utilizing backward stepwise logistical regression was developed to measure the probability of lower limb stump healing. The relationship between the dependent and independent variables was identified using univariate and multivariate logistic regression. Hosmer and Lemeshow goodness of fit test and Receiver Operating Curve (ROC) was used in order to measure the effectiveness of the model. The model was validated with the prospective data of 100 patients that had undergone major lower limb amputation from the year 2010 and 2011 in Royal Infirmary of Edinburgh prospectively. Results: In this study healing of the stump as defined was achieved in sixty three percent (63%) of patients. Univariate analysis found seven variables to be associated with lower limb stump healing (type of amputation, gender, hypertension, smoking, serum sodium, serum creatinine and serum High Density Lipid cholesterol (HDL)). A further four variables (age, diabetes xxv mellitus, white cell count and Prothrombin Time) were added to the model secondary to their strong clinical association with the stump healing. Three variables, namely serum sodium, serum creatinine and serum High Density Lipid cholesterol were identified which influenced stump healing. Patients with normal serum sodium were 75% more likely to have lower limb stump healing compared to that of patients with abnormal serum sodium (odds ratio [OR] 1.756; 95% confidence interval [CI] 1.048-2.942). Patients with normal serum creatinine were 66% more likely to have their stump healed (OR 1.664; 95% CI 0.94 to 2.946). The healing rate of patients with a normal level of serum High Density Lipid cholesterol was 75%, in contrast to patients with an aberrant level of serum High Density Lipids cholesterol (OR 1.753; 95% CI 1.061 to 2.895). The effectiveness of the retrospective stump-healing model was demonstrated by the area under the Receiver Operator Curve (0.612), which was supported by the Hosmer and Lemeshow goodness-of-fit test (p=0.879). In the prospective study, the model’s discriminatory power was verified by the area under the Receiver Operator Curve (0.584) and Hosmer and Lemeshow goodness-of-fit test (p > 0.05). Conclusion: Serum sodium, serum High Density Lipid cholesterol and serum creatinine have a strong correlation with lower limb stump healing. However, serum sodium and serum High Density Lipid cholesterol secondary to multiple co-morbidities in this cohort group could be altered secondary to disease pathology itself. Further clinical research is necessary to evaluate the association of the risk factors with lower limb stump healing.

No description available.

Shoe wear patterns have potential value in clinical diagnosis and forensic identification, although they lack rigorous study. Podiatrists have claimed understanding of shoe wear patterns, associating foot pathologies with characteristic patterns and implying a "onecondition, one wear pattern" hypothesis. This project was commenced to understand and clarify this relationship. Round one of an initial Delphi exercise to seek agreements over such wear pattern associations however indicated that, many different patterns could be associated with single named foot pathologies with round three agreements appearing to relate to the most common pattern associations. Analysis of the patterns in the Delphi exercise produced an instrument to describe and compare shoe wear patterns using focal points - points from which areas of shoe wear would spread. A following survey questionnaire suggested that podiatrists were most familiar with wear patterns associated with four foot pathologies - pronation, hallux rigidus, pes cavus and rearfoot varus. Patterns associated with these pathologies were collected from U. K. podiatrists in a single round questionnaire. Inductive analysis of these patterns from a hermeneutic phenomenological perspective using the focal point concept suggested that if the pathological context is known, wear patterns could be classified on the basis of causative function. A theoretical model was proposed of factors important in wear pattern production, suggesting that primary walking intention (the intended walking function of the foot) was more influential than foot pathologies in wear pattern formation and that "external" factors could also influence shoe wear. Validation and grounding of the focal point concept and model of shoe wear influence was planned, involving paired podiatry observers, to determine whether focal points could clarify, differentiate and show similarities between shoe wear patterns in reality and whether the model of wear influence was justified. To reduce the potential for observer error, two prior exercises were undertaken. A Delphi exercise focused participants on the required task and produced statements for the recognition of variables, which may influence shoe wear patterns. Inter-observer reliability tests demonstrated that clinical observation agreement levels were acceptable for the validation. In the validation, three subjects exhibiting pathologies, including hallux rigidus, and their owned footwear (22 items) were studied. The presence, level and effect of variables potentially influencing the wear patterns present, were determined by paired observations of foot pathologies, shoe fit and function, video analysis of foot function and subject interview for the footwear history. The focal point concept showed similarities and differences between shoe wear patterns, although wear pattern clarity limitations occurred. Within the pathological context the patterns predicted the related functions. The model of wear influence was supported with external influences needing to be major to override primary walking intention and foot pathology effects. A method to describe and compare shoe wear patterns and a model to explain the link between function and wear, showing the relationship of factors important in wear pattern production have been produced. This model provides an alternative perspective on foot function to that of biomechanical theory and could represent the basis of a new taxonomy for podiatry. This greater understanding of shoe wear patterns should improve their potential value in forensic identification and in clinical diagnosis.

An investigation into the effects of plantar foot pressure on the microcirculation of healthy subjects and patients with Rheumatoid Arthritis was carried out. In the light of no equipment available to carry out this study a new system was developed. A shoe device was built with a combined pressure/skin blood flow transducer embedded in a three-tier piston mechanism in the heel so that plantar foot pressure could be applied/removed and quantified. The skin blood flow transducer made contact with the skin and was able to collect data about the microcirculatory state of the skin. The first system developed consisted of the laser Doppler Fluxmeter (Moor Instruments Ltd., UK) used to collect skin blood flow information and incorporating a strain gauge (Kyowa Electronic Instruments Co. Ltd., Japan) to quantify plantar foot pressure applied to the centre of the heel. This system was visually/sound synchronised and due to the time delay error it was modified. For the final system developed, the strain gauge was replaced with a custom-made Novel capacitative transducer (Novel, Germany) to quantify pressure. This allowed for the pressure system to be electronically synchronised in real time with the laser Doppler fluxmeter using an electronic synchronisation box. A number of studies were carried out to validate the systems. The developed systems were used to: (a) investigate the effects of the venoarteriolar response in healthy subjects with regards to the effects of plantar foot pressure on skin blood flow. The study concluded that subject positioning (that is, supine or semi-weight bearing) has an effect on how the microcirculation of the skin reacts to applied pressure. Thus, studies investigating the effects of external pressure on skin blood flow must have their subjects in a position that is related to what is being studies; (b) investigate the effects of plantar foot pressure on skin blood flow in patients with Rheumatoid Arthritis. A healthy control group was compared with a cohort of patients with Rheumatoid Arthritis with no evidence of vasculitis. The study concluded that there were no significant differences between both groups. A number of articles have been published from this thesis (see Appendix 14).

Rheumatoid Arthritis (RA) frequently affects the foot. Custom moulded foot orthoses are effective in the management of the foot in RA; however the process of manufacture is lengthy, resulting in a delay of treatment for the patient. Offthe- shelf foot orthoses can be dispensed at the chairside on the day of diagnosis, so the patient receives treatment immediately. This is particularly crucial in RA, as early intervention is thought to improve patient outcomes in the long term. Anecdotal evidence suggests that Podiatrists do prescribe off-the-shelf foot orthoses for the management of the foot in RA; however no clinical studies exist to support this practice. The aim of this study was to investigate any potential effects on the foot of one commonly prescribed off-the-shelf foot orthosis, in patients with early RA. The type of off-the-shelf foot orthosis used was the Slimflex™ Plastic which has been shown to be a commonly used off-the-shelf foot orthosis by Podiatrists in the management of patients with RA in Scotland (Cameron et al. 2009). A total of 35 patients diagnosed with RA, with a mean age of 52.4 years (SD 13.3 years) and median disease duration of 0.5 years (IQR 1.8 years) were included. Local ethical approval was obtained. The study used a repeated measures design, with data collected at baseline, three months, and six months when patients were barefoot, shod, and with foot orthoses, to investigate any effects over time and between conditions. The primary objective was to investigate any potential effects of the Slimflex™ Plastic off-the-shelf foot orthosis on foot health related quality of life (QOL) using the Leeds Foot Impact Scale (LFIS) and foot pain using the Visual Analogue Scale (VAS). Plantar foot pressure measurement, walking speed, foot stability during walking and foot kinematics were then investigated to provide a rationale as to why foot health related QOL and foot pain may be affected with the foot orthosis. Data was analysed using SPSS version 16.0. Due to the known potential effects of medication, data was analysed for the total patient group (n=35) and subanalyses were then carried out on the group of patients who presented with stable medication throughout the study (n=12). This enabled any changes to be attributed to the foot orthosis alone and not because of any effects of medication. The LFIS and VAS for foot pain were significantly lower with the use of the foot orthosis over six months (p<0.05). Peak plantar pressure at the forefoot increased between barefoot and shod, and barefoot and foot orthosis (p<0.05), but decreased between shod and foot orthosis (p<0.05). Pressure time integral at the forefoot reduced with the foot orthosis (p<0.05). There was an increase in contact area at the midfoot and in hallux and lesser toe contact area, with the orthosis (p<0.05). Walking speed also increased over the six months (p<0.05). Preliminary findings indicated that the orthosis may affect foot stability during walking, and a case study implied that the foot orthosis positively affects foot kinematics. This study suggests that the Slimflex™ Plastic off-the-shelf foot orthosis is effective in the management of the foot in early RA, according to the measured variables in this study.

Introduction - Currently there is limited evidence supporting podiatric treatment of children with JIA. The foot orthoses (FOs) prescribed to JIA children so far appeared to be very expensive and required long time to manufacture before the fitting. This randomised controlled trial (RCT) aimed to determine whether pre-formed FOs that can be prescribed at chair side, impacted on pain, quality of life (primary outcomes) and/or gait-parameters (secondary outcomes) in children affected by JIA. Methods - The study took place at the Gait Analysis laboratory at Queen Margaret University – Edinburgh and at the TORT Centre, Ninewells Hospital-Dundee. Children with JIA were diagnosed according to the ILAR criteria. Intervention was blinded to the patients. The trial group received Slimflex-plus FOs, with the addition of chair side corrections and the control FOs supplied were made with leather board (1mm thick) only. Both FOs had the same black EVA top cover. Primary outcomes were investigated using validated questionnaires (VAS, CHAQ and PedsQL). Tekscan™ equipment (F-Scan™ and HR Walkway®) measured secondary outcomes in-shoe pressure and force data with and without FOs intervention. Multiple foot strikes and repetitive gait patterns were compared pre and post-treatment. Primary and secondary outcome measures were recorded at baseline, 3rd and 6th month’s period. Results - Sixty children were recruited; 48.3% (n=29) control and 51.7% (n=31) active treatment group. Within the control group 20.7% (n=6) of patients were male. Within the active treatment group, 29% (n=9) subjects were male. Age ranged between 5 to 18 years, median age for the control group was 11 (range=12.90) and for the trial group were 11.50 (range=12.11). In order to attribute any effect solely on the FOs intervention, details of changes of medication and/or new joint injections were recorded during the trial. In the control group 65.5% (n=19) were considered to be prescribed with stable medications. Similarly, amongst children receiving active treatment 74.2% (n=23) were deemed to be taking stable medications. Overall, 99.4% (n=179/180) appointments were completed, only one subject did not attend the 6 month session. Significant improvement was identified in the primary outcomes favouring active treatment with regards to pain and quality of life measures: VAS (p<0.05); CHAQ (p<0.05); PedsQL paediatric-generic (p<0.05) Peds paediatric rheumatology (p<0.05); PedsQL parent-generic (p<0.05); PedsQL parent-rheumatology (p<0.05). In all these quality of life tools where p<0.05, clinical significance was also obtained. Significant differences were also identified between the groups for gait time, stance time, total plantar surface, heel contact, midfoot, 5th metatarsal head and distal phalanx. Discussion - The results strongly suggest that FOs are effective in improving pain, quality of life and most gait parameters in JIA children. FOs can be customised at chair-side so JIA children can receive immediate podiatric benefit from the same day of the biomechanical assessment. Compliancy rate proved to be extremely high confirming that the podiatric treatment is well accepted by JIA children. Conclusion - Primary and secondary outcome’s results, strongly support the use of FOs in the treatment of JIA children, which highlights the important role of the podiatrists within the multidisciplinary team in paediatric rheumatology.

Aim To develop a list of red flag clinical indicators for possible serious pathology masquerading as, or presenting alongside, neck related musculoskeletal disorders in the adult population. Background Musculoskeletal physiotherapists provide assessment and treatment for pain and functional impairments relating to musculoskeletal disorders, such as back and neck pain. In order to apply safe and effective treatment to these conditions it is vitally important that any underlying serious complaints have been excluded. Clinical indicators known as ‘red flags’ have been developed for diagnostic triage in back pain to help identify serious underlying conditions, such as cancer and infection. Red flags for serious pathology in neck pain or neck related pathology has not received the same level of attention as red flags in back pain. A literature review identified inconsistent evidence for clinical tests and clinical indicators for serious pathology in neck related musculoskeletal disorders. This presents a serious clinical challenge for musculoskeletal physiotherapists. Method A mixed method study design was developed involving: a) Qualitative descriptive method through Physiotherapy focus group; and, b) Three round Delphi survey method involving consultant neurologists and consultant neurosurgeons. The Delphi method involves combined qualitative and quantitative data phases. Thematic content analysis was used to analyse the qualitative data. A combined descriptive and inferential (non-parametric) statistical analysis was used to analyse the quantitative data. Kendall’s W (Kendall’s coefficient of concordance) was used to evaluate the level of consensus across all participants for the quantitative phase of the Delphi method. Findings A list of neck related red flag clinical indicators within five specific categories were developed: 1. progressive pain; 2. cancer, infection, trauma; 3. neurological deficit (spinal cord compromise); 4. headache (associated with neck pain/stiffness); 5. brainstem, cervical arterial and cranial nerve dysfunctions. An increase in Kendall’s W was demonstrated between Rounds 2 and 3 in four out of five categories, indicating an increase in consensus levels between participants. This process highlights the complexity of interpreting clinical features within musculoskeletal presentations.

Clinical guidelines and policies recommend exercise after stroke. Person-centred goal setting may facilitate the uptake and maintenance of physical activity. The aim of this work was to design and evaluate a goal setting intervention in an exercise after stroke setting. Five interlinked studies were undertaken within the development and feasibility stages of the MRC framework of complex interventions. A systematic review examined 17 observational studies (11 quantitative, six qualitative) for the effects and experiences of goal setting in stroke rehabilitation (study one). Despite some positive effects, no firm conclusion could be reached regarding its effectiveness. Patients and professionals differed in their experiences. Barriers to goal setting outnumbered facilitators. The lack of a standardised goal setting method in stroke rehabilitation was highlighted. A goal setting intervention tailored to exercise after stroke was developed in study two, based on: findings from study one, Bandura’s Social Cognitive Theory and the Canadian Occupational Performance Measure. The intervention components were: dedicated time, patient education, patient involvement, regular follow-up, and a purpose-designed workbook. This intervention was piloted in study three alongside validation of the activPAL™ activity monitor with 12 stroke survivors. The intervention did not require modification. Only two variables of the activPAL™ (time spent in sitting and upright) had acceptable validity and reliability. Feasibility of the intervention and users’ experiences were investigated in study four with four stroke survivors, using mixed methods case studies. Intervention delivery and compliance were acceptable with no adverse effects. Findings regarding acceptability and content suggested a need for further work. Participants’ interest and engagement in goal setting were influenced by their familiarity with goal setting, interest in physical activity, functional ability and levels of self-efficacy, highlighting the individualisation required within goal setting. Experiences of exercise professionals involved in exercise after stroke regarding goal setting were explored in study five through three focus groups (n=6; n=6; n=3). Although goal setting was viewed positively, participants felt that its potential effectiveness was not always translated into practice due to barriers encountered: clients’ readiness to change, professionals’ lack of knowledge about stroke and a number of organisational factors. Suggestions to improve goal setting in practice were discussed. This work has enhanced our understanding of goal setting as a complex intervention. Recognition of the potential benefits of goal setting by both service users and providers, amidst the challenges, argues in favour of goal setting in the exercise after stroke setting. Areas for further research have been discussed.

Introduction: A suitable type of vascular access has to be created to establish a connection between the circulation system of the patient and the haemodialysis cycle. The arteriovenous fistula (AVF) is considered to provide the best long-term functional vascular access, with reduced risk of thrombosis or infection and cost-effective. However, significant numbers of AVF, which fail to develop sufficiently for dialysis, are 28-53% of cases. This study aimed to explore the potential influence of blood markers and factors on the maturation of AVF, in patients who have undergone vascular access surgery and to develop and validate a prognostic model to determine the success of AVF maturation. Methods: Data from 300 patients was retrieved who had undergone AVF surgery between the years 2006 and 2009, from the Royal Infirmary of Edinburgh. A prognostic model was developed for the prediction of maturation of AVF using backward stepwise logistical regression. This data was analysed using univariable, multivariable logistic regression. Model performance was assessed, using the receiver operating characteristics (ROC) curve and Hosmer and Lemeshow goodness of fit test. A prognostic model was validated with the prospective data of 100 patients who had undergone AVF surgery between the years 2009 and 2011, from the Royal Infirmary of Edinburgh. Results: Three variables were identified, which independently influenced fistula maturation. Males were twice as likely to undergo fistula maturation, compared to that of females (odds ratio (OR) 0.514; 95% confidence interval (CI) 0.308 to 0.857). Patients with no evidence of Peripheral Vascular Disease (PVD) were three times more likely to mature their fistula (OR 3.140; 95% CI 1.596 to 6.177). A pre-operative vein diameter greater than 2.5mm resulted in a fivefold increase in fistula maturation compared to a vein size less than 2.5mm (OR 4.532; 95% CI 2.063 to 9.958). The model for fistula maturation had good discrimination as indicated by area under the ROC curve 0.677 and calibration as indicated by Hosmer and Lemeshow test (p = 0.79). The model discriminatory power was confirmed in the prospective study (validation data set) with area under the receiver operating curve was 0.59 and calibration indicated by Hosmer and Lemeshow test (p > 0.05). Conclusion: Successful vascular access provision is the foundation on which successful haemodialysis is built. This study has found that female gender, history of PVD and vein diameter less than 2.5 mm are the negative significant independent clinical predictors of maturation of arteriovenous fistula.

Introduction – The pathogenetic vision of diabetes mellitus has changed in the last few years, with inflammatory and autoimmunity pathways playing roles in the development and progression of diabetic complications. This study was conducted to investigate whether inflammation and/or autoimmunity are associated with the pathogenesis of human diabetic peripheral neuropathy. Methods – A cross-sectional analysis was initially conducted to explore the population of patients with diabetes mellitus in the Kingdom of Bahrain. The demographics of patients diagnosed with diabetes mellitus in the Royal Medical Services-Bahrain Defence Force Hospital were randomly collected from 500 record cards. Case-control analysis included three groups: 30 patients with diabetic peripheral neuropathy, 30 patients with diabetes mellitus without neuropathy, and 30 healthy controls. Blood analysis was conducted to compare the levels of pro-inflammatory markers and autoimmune markers between the three groups. Secondary analysis investigated the correlations between the level of markers and sample demographics and neurological manifestations. Due to the limited time and financial resources available, this research was considered as a pilot/exploratory study encouraging further investigations to take place in the near future. Results – From the 500 sample initially selected, 48% were male (n=242) and 52% (n= 258) were female. The mean age was 55 ± 14 years and the mean BMI was 35 ± 9 kg/m². Type I DM was present in 8% (n=38) only as opposed to 92% (n=462) who had type II DM. From the sample randomly selected, 76% of the patients had other medical complications, the commonest being peripheral neuropathy; 26% (n=186) followed by vascular insufficiency; 20% (n=141). Case control analysis demonstrated very highly significant differences between the three groups in the levels of IL-6, IL-8 and IL-1β (p<0.001), highly significant differences in the levels of TNF-α, IFN-ɤ (p<0.01), and a significant difference in the levels of CRP (p<0.05). Highly significant differences between the percentages of positive and negative autoimmune antibodies (ANA) between the three groups were observed. The odds of positive values of ANAs in the neuropathy group were 50 times higher when compared to control groups. Secondary analysis detected a number of significant relationships between the levels of pro-inflammatory markers and sample demographics. Highly significant correlations were found to be associated with neurological characteristics in the neuropathy group at the levels of CRP, IL-8, and IL-1β. Conclusion – The present study demonstrated that human peripheral diabetic neuropathy is associated with increased biochemical markers of inflammation and autoimmunity. Furthermore, painful neuropathy may be associated with further increase in inflammation. These results indicate that inflammation and autoimmunity may be important contributors in the development of peripheral neuropathy in diabetes mellitus. The new pathogenic factors may lead to the consideration of new management plans involving new therapeutic approaches and disease markers.