The objective of this study was to investigate the intra-rater (within day & between days) and inter-rater reliability of foot/ankle water volumetry in healthysubjects.Study design: Repeated measures design with 2 raters.Background: Physiotherapists more often aim to reduce swelling in the acute phase of soft tissue injury. Reduction in swelling will hasten the healing process. Therefore swelling forms an important outcome measure that is worth studying during the healing process to determine the efficacy of the intervention. Though there are different methods available to measure extremity swelling, water displacement method is widely used in physiotherapy studies. Although water volumetry has been used to assess the reduction in swelling over time, there is paucity of reliability studies that have assessed the between-days reliability.Methods: Thirty normal subjects with asymptomatic ankles were measured by 2 raters. Three repeated foot volume measurements were performed by each of the rater using water volumetry during a single test session. The same procedure was repeated approximately at the same time on the 3rd day and 5th day following the 1st measurement day by the same raters on the same subjects. The raters were blinded to each other's measurements. The order for rater's volumetric measurement on each subject on each day was determined by a random chart produced by SPSS. The reliability was measured in terms of systematic bias (Paired t test & Bland & Altman's plot), absolute reliability (Limits of Agreement [LOA] & Standard Error of Measurement [SEM]) and relative reliability (Intraclass Correlation Coefficient [ICC]).Results: There was no systematic bias between any of the trials within day/between days or between raters. The intra-rater reliability within day as calculated by ICC; LOA and SEM were 0.99, ±10ml and ±3.5ml respectively and for between days reliability the values were 0.99 (ICC), ±20ml (LOA) and ±7ml (SEM) and for interrater reliability the values were 0.99 (ICC), ±13ml (LOA) and ±5ml (SEM). The results demonstrated that water volumetry method was highly reliable within day and between days for both the raters; and highly reliable between raters.Conclusion: Water volumetry is a highly reliable method for measuring foot/ankle volume repeatedly on different days. The random error range in milliliters (ml) as estimated by the absolute reliability indices provides the practical use of this method in a clinical/research setting.

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)

Introduction: Ankle injuries are among the most prevalent acute musculoskeletal injuries, and are a significant burden on any health system. The interaction of the physiotherapist with the patient and their mutual understanding of impairments, function and recovery are important to achieving a satisfactory return to work and leisure activities. To date, little attention has focused on this interaction. There is a need for further exploration of differences and associations between outcome questionnaires that investigate similar domains of pain and function, and whether scores from such outcome measures are related to the patient’s perception of function and recovery. Of further interest is whether there are relationships between impairment measures and perceived function, and how actual performance of tasks might influence the patients understanding of their capabilities. To provide a more complete picture of these relationships, a ‘mixed methods’ approach using qualitative research methods within a quantitative study was thought to be most appropriate. The overall aim of this thesis was to utilise this research approach to investigate patients’ perceptions of their recovery and elucidate factors important to both therapists and patients that ultimately might enhance their understanding of recovery from an ankle injury. Literature reviews: Three literature reviews were undertaken. Firstly a review of systematic reviews investigating ankle sprains identified a wide variety of management strategies. There was a lack of strong evidence to support any particular management strategy. Hence clinicians are likely to have difficulty setting appropriate rehabilitation plans. Secondly a critical review identified a number of different outcome questionnaires that were utilised to gauge recovery level; however, justification for their selection was often lacking. This review also identified that little emphasis was placed on understanding the patients’ perception of their injury and the rehabilitation process. A final critical review investigated impairment and performance measures and identified four specific areas that were focused upon by clinicians during the treatment of ankle sprains: joint position sense, postural control, strength and performance during function. However, only weak evidence was found for there being a deficit in joint position sense, postural control and strength in the injured limb following an ankle sprain, and inconclusive evidence of deficits in physical performance of tasks related to function. Methods: Forty participants with an acute sprained ankle were recruited along with their treating physiotherapist. The participants completed a Global questionnaire, the Lower Limb Task Questionnaire (LLTQ) and the Short Form -36 (SF-36) Questionnaire at the initial visit, at discharge and at a six week follow up visit where they also undertook impairment testing involving, joint position sense, postural control and strength along with a functional performance test and selected functional activities. Ten participants were purposefully selected to undertake semi-structured interviews. The treating physiotherapists completed global questionnaires at the initial visit and at time of discharge. An interpretive hermeneutic approach was undertaken to examine the participants’ perceptions. Results: There were equal numbers of males and female participants and the average age of participants was 30.5 years. The relationship between questionnaires for the domains of pain and function varied between low and high degrees of association. The global limitations scores between the participants and physiotherapists were similar at the initial visit, whereas on discharge the participants had a significantly lower score (p<0.05) compared to the physiotherapists. With respect to impairment testing, there was a significant difference (p<0.05) between the uninjured limb compared to the injured limb for the joint position sense and performance agility hop test. All other comparisons of impairments were not significant (p>0.05). There was no association between questionnaire scores and impairment measures (p>0.05). Additionally there were no significant associations between previous injury and questionnaire scores and impairment measures. Finally in relation to the performance of specific functional tests there was a significant difference (p<0.05) between the six week follow up LLTQ score and the score following actual performance of the test. The findings of the participants’ interviews identified three key concerns. Firstly, that participants have a limited understanding of questionnaires, and secondly, that there is a difference in understanding of ‘recovery’ between the therapist and the patient at time of discharge. Thirdly, there was dissociation between outcome measures and the patient’s perception of their own recovery. Conclusions: This study revealed a lack of understanding and effective communication concerning physiotherapy practice in relation to ankle sprains. It was apparent that questionnaires purporting to measure similar constructs are at times dissimilar in scores and are not related strongly. Care needs to be taken in selecting and interpreting outcome measures particularly in relation to questionnaires. It was also apparent that caution should be exercised when considering the influence of impairment measures upon function. Physiotherapists should be aware that patients may perceive a lack of confidence in their level of function at the time of discharge. As a result physiotherapists need to incorporate strategies to improve patient confidence in their management plan.

Spinal cord injury (SCI) manifests signs of spasticity, plantar flexor (PF) hyperreflexia and ankle clonus, and deficits in motor function. In individuals with motor-incomplete SCI (MISCI), ankle clonus may limit independent walking function. Ankle clonus is attributed to enhanced soleus stretch reflex (SSR) excitability due to decreased supraspinal input and maladaptive reorganization of spinal reflex circuitry. We explored these questions: 1. What are the biomechanical, clinical, and neurophysiologic correlates of ankle clonus? 2. Does locomotor training improve ankle clonus and walking function? 3. Will operant conditioning-based interventions that increase tibialis anterior activation or decrease soleus reflex excitability improve ankle motor control and walking function? In Chapter 2 we compared Ankle Clonus Drop Test (Drop Test) measures with clinical and neurophysiologic measures. Drop Test measures were highly reliable and exhibited moderate to strong correlations with clinical and neurophysiologic measures. Analysis of EMG activity during clonus revealed a predominant pattern of antagonist coactivation. In Chapter 3 we investigated the effects of locomotor training on PF and quadriceps spasticity, and walking function. We assessed responsiveness of the PF reflex threshold angle, a Drop Test measure of PF spasticity. PF and quadriceps spasticity decreased after locomotor training and were moderately correlated with increased walking speed. The PF reflex threshold angle measure discriminated between individuals with and without clonus. In Chapter 4 we compared the effects of two operant-conditioning based interventions to, (1) increase TA EMG activation (TA↑) and (2) decrease SOL H-reflex amplitude during active dorsiflexion (SOL↓), on reflex modulation, ankle motor control, and walking function. Each intervention improved walking function; however, modulated the variables in unique ways. TA↑ improved deficits of strength and range of motion, and SOL↓ improved modulation of SSR and SOL/TA coactivation. In Chapter 5 we discussed implications of our conclusions: (1) Drop Test ankle clonus measures are valid, reliable, and responsive; (2) antagonist coactivation was predominant during ankle clonus; (3) in individuals with chronic MISCI, locomotor training decreased PF and quadriceps spasticity and improved walking function; and (4) an operant conditioning-based intervention to either increase TA strength or decrease SOL reflex excitability improved spinal reflex modulation and walking function.

Bakgrund: Truppgymnastik är en relativt ung tävlingsgren inom gymnastik med ursprung från de Nordiska länderna. I Sverige är det den mest utövade formen av tävlingsgymnastik med flest rapporterade  skador i nedre extremiteten samt återkommande besvär i ryggen. Tester i syfte att förebygga skador är efterfrågade och få studier har utvärderat tester för idrottande barn och ungdomar. Syftet med studien var att beskriva en grupp unga truppgymnaster utifrån bakgrundsvariabler, och rörelsekontroll med screeningtestet Performance Base Matrix samt att mäta förekomst av muskuloskelettala skador under en period på sju månader.  Metod: Nitton unga truppgymnaster (flickor,7-9 år) genomförde screeningtestet Base Matrix i syfte att bedöma deras rörelsekontroll vid låg respektive/ low threshold och hög belastning/ high threshold. Testerna analyserades visuellt och genom videoupptagning. Resultatet av testerna dokumenterades i ett protokoll som bearbetades on-line samt för beräkning av procentuell förekomst av sämre utförd test i form av svaga länkar. Information om skadeförekomst inhämtades från föräldrar och tränare. Resultat: Alla försökspersoner genomförde screeningtesterna i sin helhet. Försökspersonerna hade en medelpoäng av 15 (max 50), där fler poäng anger fler svaga länkar/ weak links. Vid låg belastning var ländrygg/bäcken i flexion/ Low back/pelvis flexion den mest förekommande svaga länken (58%). Vid hög belastning var anterior rotation i skuldran / shoulder tilt den mest förekommande (63%). Tre skador rapporterades under tidsperioden: två fotledsskador och ett nackbesvär.  Konklusion: Denna studie indikerar att screeningtestet Base Matrix är genomförbart på unga truppgymnaster. Resultaten visar att skuldra framför allt under hög belastning samt ländrygg/bäcken framför allt under låg belastning är områden som uppvisar flest svaga länkar. Detta indikerar att dessa områden vore särskilt att beakta i skadeförebyggande träning av unga truppgymnaster. / Background: Team gym is a relatively new kind of competition in gymnastics with its origin from the Nordic countries. In Sweden it is the most practiced form of competitive gymnastics. Correlations have been found between altered trunk control and injuries in the extremities. Injury prevention testing is performed more frequently and tests requested for improving the training regimen.The purpose of this study was to describe a group of young team gymnasts regarding background variables, test results from Performance Base Matrix screening test and injury incidence during a period of seven months. Method: Nineteen team gymnasts, 7-9 year-old, were screened with the protocol Base Matrix for uncontrolled movement (weak links) under low and high load (threshold). Background data were collected on age, height, weight, dominant side, injuries in the recent year and the practice of other sports. The coaches were asked to register the number of injuries over a period of seven months.Results: The mean age was 8.8 years, BMI 16.1, 89% were right-handed and the average value of the Base Matrix score of 15 out of 50. Two injuries to the ankle and one on the neck reported totally from coaches and parents. Among the most apparent weak links were Low back / pelvis flexion at low load (58% of group) while the shoulder tilt at high load (63% of the group).Conclusion: The result indicates that the Base Matrix screening test is ​​feasible to use in young gymnasts. More studies are needed to confirm the results. The result indicates that the shoulder especially under high load and the lower back especially under low load were the body segments that showed the most weak links. These parts of the body are the most important to take  into consideration in the training of the young team gymnasts.

Background: Peripheral arterial disease (PAD), as a consequence of atherosclerosis in the arteria of the limbs, affects one of ten Swedes older than 65. PAD can develop slowly and silently, and involves an increased risk for cardiac infarction and stroke. Measurement of the patient´s ankle blood pressure and calculation of the ankle-brachial index is an evidence-based method to discover PAD. Objective: To investigate how district nurses and general practitioners perceive this method of examination and experience possible obstacles to why it is not more commonly applied at primary health care centres. Method: Data collected by semi-structured interviews have been processed by qualitative content analysis with a manifest onset. Results: The participants described a lack of routine for the measurement of ankle blood pressure at their health care centres. In their experience the cooperation of district nurses and general practitioners was characterized by insufficient information and unclear roles. Conclusion: As a consequence of lacking routines and indistinct roles at the health care centres, measurement of ankle blood pressure was not always performed as indicated in the guidelines. More knowledge and established routines could have led to better care for patients with PAD. / Bakgrund: Perifer artärsjukdom till följd av ateroskleros (åderförfettning eller åderförkalkning) i benens pulsådror drabbar en av tio svenskar över 65 år. Sjukdomen, som länge kan vara symtomfri, medför en ökad risk för hjärtinfarkt och stroke. Ankeltrycksmätning och beräkning av ankelbrakialindex är en evidensbaserad metod för att upptäcka perifer artärsjukdom. Syfte: Att beskriva hur distriktssköterskor och distriktsläkare uppfattade mätning av ankeltryck, beräkning av ankelbrakialindex och eventuella hinder för att använda metoden inom primärvården. Metod: Data samlades in med hjälp av semistrukturerade intervjuer och analyserades med hjälp av kvalitativ innehållsanalys med manifest ansats. Resultat: Informanterna upplevde att rutiner för att mäta ankeltryck saknades på deras vårdcentraler. I stället var det upp till informanterna själva att avgöra om och när de skulle mäta. Samarbetet kring patienterna mellan distriktsläkare och distriktssköterskor präglades av bristfällig information och oklara roller. Slutsats: Avsaknaden av rutiner och en otydlig rollfördelning ledde till att ankeltryck inte alltid mättes på de patienter som borde ha undersökts med hjälp av metoden. Bättre kunskaper och rutiner för ankeltrycksmätning i primärvården skulle kunna leda till säkrare vård för patienter med perifer artärsjukdom.

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Research Objective Patients with chronic kidney disease (CKD) are at increased risk for atherosclerosis and peripheral artery disease (PAD). PAD has received far less attention than coronary artery disease (CAD) in CKD patients. Few studies have examined risk factors for PAD in CKD. We studied the possible related risk factors and benefit of hypertension treatment in CKD patients with PAD. Data Sources We included 129 patients of both sexes with stages 3 to 5 of CKD, as described by the Kidney Outcome Quality Initiatives (K/DOQI ) classification, without receiving dialysis therapy, not previously diagnosed with PAD. Study Design The following information were collected within six month period, including demographic characteristics, history of hypertension, anti-hypertension drug, diabetes, smoking, and pre-existing cardiovascular disease, body mass index (BMI), fasting blood glucose, HbA1c, total cholesterol, triglyceride(TG), high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol(LDL), calcium (Ca), phosphate(P), Albumin, uric acid, urine protein. Ankle-brachial index (ABI) is a noninvasive diagnostic test that is efficient in detecting asymptomatic PAD with ABI <0.9. Findings There were 22 (17.7 %) participants with PAD. Higher systolic blood pressure (SBP), higher diastolic blood pressure (DBP), higher pulse pressure showed strong association with PAD in CKD patients. On further analysis, significant fewer patients treated with calcium channel blocker (CCB) in hypertensive CKD patients with PAD (£q2 =7.055, p =0.008). The multivariate logistic regression analysis in hypertensive patients demonstrated the risk factors for PAD was pulse pressure, and Calcium channel blocker treatment may correlate with decreasing PAD formation (odds ratio= 0.232, 95% CI=0.07-0.73, p =0.013) in CKD patients. Conclusion There is a high prevalence rate of PAD in population of CKD, especially those with hypertension. ABI should be routinely examined in these patients who can benefit earlier from therapeutic measures.

Repair and remodeling of bone during healing and fusion require a combination of bone resorption and formation to successfully restore the bone to its previous strength. The healing process is highly responsive to the mechanical conditions of the construct, where excessive loading can cause high strains that delay healing, but moderate loading can be beneficial. Maintaining compression at the site of fracture can benefit healing by maintaining bone congruency and increasing the stability of the bone-implant construct to prevent excessive shifting. For these reasons, compressive mechanisms are employed in many orthopaedic devices, including both intramedullary (IM) nails and external fixators for ankle arthrodesis applications. Tibiotalocalcaneal (TTC) arthrodesis is a salvage procedure that fuses both the ankle and the subtalar joints. It has become the standard of care in ankle degeneration, which can be brought on by posttraumatic arthritis, failed total ankle arthroplasty, or diabetic conditions such as Charcot arthropathy. While current devices are effective in many cases, TTC arthrodesis procedures still incur failure rates as high as 22%, where failure of the bones to successfully fuse can result in amputation. Because bone healing relies upon bone resorption, the initial compression applied to the implanted constructs can be quickly lost, which may sacrifice the stability of the structure and delay or inhibit further healing. By employing a mechanism that can sustain compression during the bone healing process, it was possible to increase the stability of the construct even during bone resorption, minimizing the failures that still occur. The focus of this study was to determine the effects of compression on the mechanical stability of the implant-bone construct found in TTC arthrodesis. A comparison was made between the torsional stability of two currently marketed intramedullary devices, as well as a prototype IM device comprised of a nickel titanium core, designed to hold constant compression for up to 9mm of resorption. Additionally, the stability of each construct over time was evaluated by correlating bone resorption to a loss in compressive force.

Individuals with various lower-limb neuromuscular and musculoskeletal impairments are often prescribed passive-dynamic ankle-foot orthoses (PD-AFOs) to compensate for impaired ankle muscle weakness. Several studies have demonstrated the beneficial effects of PD-AFOs on pathological gait, but few studies have examined the influence of the AFO stiffness characteristics on gait performance. One challenge to performing such studies is the difficulty of manufacturing custom AFOs with a wide range of controlled stiffness levels. However, selective laser sintering (SLS) is a well-suited additive manufacturing technique for generating subject-specific PD-AFOs of varied stiffness. Therefore, the overall goal of this study was to use SLS manufactured PD-AFOs to identify the relationships between AFO stiffness and gait performance in patients with various lower-limb neuromuscular and musculoskeletal impairments. Six subjects with unilateral impairments were enrolled in this study. For each subject, one subject-specific PD-AFO equivalent to the subject’s clinically prescribed carbon fiber PD-AFO (nominal), one 20% more compliant and one 20% more stiff were manufactured using SLS. Three-dimensional kinematic and kinetic data were collected from each subject while ambulating with each PD-AFO at two different speeds to allow a comprehensive biomechanical analysis to assess the influence of PD-AFO stiffness on gait performance. The results showed that in the compliant AFO condition, the AFO limb vertical ground reaction force (GRF) impulse during loading and the non-AFO limb medial GRF impulse during push-off decreased. In addition, the AFO limb braking GRF impulse during loading and the non-AFO limb braking GRF impulse in early single-limb stance decreased. Furthermore, in the compliant AFO condition, negative knee work during early single-limb stance increased while positive hip work in early swing decreased in the AFO limb. Overall, as AFO stiffness decreased, the AFO limb contributed less to body support and braking. In addition, a decreased medial GRF impulse coupled with an increased vertical GRF impulse during non-AFO single-limb stance suggests that walking stability may be compromised as AFO stiffness decreases. Thus, a tradeoff may exist between preserving stability and increasing net propulsion, which should be considered when assessing the mobility needs of individuals prescribed PD-AFOs as a result of various neuromuscular and musculoskeletal impairments. / text