Hallux rigidus (HR) is the second most common pathology affecting the first metatarsophalangeal joint and a primary cause of morbidity and disability. Classification of this condition helps to inform management. Over the years a number of formal HR classification systems have been devised but despite this collective experience there is no consensus on classification design, construction, application or parameters’ validity. The aim of this research was to develop an evidence-based classification framework for HR and establish its validation and reproducibility. This was achieved through four studies. An initial study of 110 patients was used to determine the clinical parameters of HR. In addition to other pertinent findings this showed a positive relationship between second toe length and first metatarsophalangeal joint pain (P<0.001). Correlations were found between first metatarsophalangeal joint pain and pes planus (r=0.84, P=0.05) and between reduced first metatarsophalangeal joint range of motion and hallux abductus interphalangeus (r=0.92, P=0.05). A second study examined the radiological parameters of HR (in the same population). Amongst other relevant findings comparison of joint space narrowing with either hallux abductus interphalangeus (P<0.005) or osteophyte severity (P<0.002) was established. Intra and inter-rater reliability studies were undertaken for all parameters. Overall, inter-rater reliability was poor. Only 28% of angular inter-rater measurements fell within a 5° range. A fourth study was used to determine ‘expert’ opinion on HR classification using semi-structured interviews. The results revealed the need for consensus agreement among clinicians and patient involvement in creation and substantiation of classification content. This research has provided a new understanding of HR classification and informed the development of a HR classification framework based on history, clinical and radiological domains. The established framework provides more than just a measure of severity and includes other dimensions such as contributory factors and functionality. Depending on its context, other applications include use as a diagnostic tool, establishing HR prevalence, monitoring progress, and surgical decision making. An algorithmic approach can enable the classification framework to be applied in different contexts proving clinical relevance and meaning to a range of professions. This research also highlights that classification parameters should be validated, reliable, sensitive, quantifiable and few in numbers and that there is a requirement to provide a ‘gold standard’ against which future HR research can be compared.

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

This study examines the impact of the transition from diploma to degree on the initial education and training of three para-professions in England; chiropody, occupational therapy (OT) and radiography. It focuses on the nature of and reasons for changes to their initial professional education and training and the potential impact of these changes on their professionalisation. The study adopted a multiple method approach; a historical review, which included documentary sources and interviews with key informants, aimed at identifying how and why these three para-professions wanted to achieve all-graduate entry, and the use of case studies to explore the differences between the diploma and degree courses. It is concluded that the achievement of all-graduate entry for these para-professions was an unintended consequence of the policies of the then government. As a result of the achievement of all-graduate entry changes were made to the respective diploma courses of these para-professions. The extent of these changes were related to the level of control and influence that the professional bodies exercised over the diploma courses. All the degree courses shared the following features: the development of autonomous, reflective practitioners who are life-long learners, an emphasis on theory rather than practice, and emphasis on propositional knowledge and the study of research methods. Although the degree courses for these para-professions achieved approval from HEIs it is argued that degree education is a contested concept. It is apparent that the para-professionals believed that the achievement of all-graduate entry would improve their professional status. However, it is evident from the study findings that it served to maintain rather than enhance their social status and market position. Changes to the initial education and training of these para-professionals were the results of the para-professionals having to respond to prevailing social, political and economic circumstances. If they had not taken this action it is suggested that their social status and market position may have been adversely affected.