Abstracts from the College of Podiatry Annual Conference 2019

Background: The global health burden is now dominated by chronic non-communicable conditions such as cardiovascular disease and diabetes that can have a significant impact on foot health. This is in the context of an ageing population with widespread implications for the individual, their carers’, and the delivery of healthcare services. For a foot health treatment plan to be effective it often needs proactive patient engagement yet engaging patients in good health behaviours can be challenging. Therefore, ascertaining a deeper understanding of people’s perceptions toward feet and foot health is integral to developing impactful foot healthcare strategies to prevent a loss of foot ill health and disease progression.

Method: Digital and traditional tools were used to collect data to explore perceptions of feet and foot health across people from a broad spectrum of demographic, cultural and social backgrounds. A social media data mine was conducted to establish the content of foot-related conversations. This data was used to inform an interview schedule for one-to-one interviews and group activities with children and young people. Thematic analysis was used to analyse the data. Alongside traditional methods, digital tools were utilised to recruit participants, targeting interest groups that can typically have an interest in foot health such as sports or pathology specific open and closed groups, and the use of related hashtags in Twitter. Ethical approval was gained to disseminate video vignettes of the narratives on the ‘Why Feet Matter’ website as a health promotion resource.

Results: Findings at this stage indicate 4 central themes. When a person is connected to others with shared symptoms it appears to reduce the health burden; an indiscriminate trust of information sources; the clinical significance of the pathology doesn’t necessarily correlate to impact levels; and the impact on the person doesn’t always correlate with concordance with self-management.

Conclusion: These findings demonstrate the need to ensure verifiable healthcare sources, especially in the digital age, yet also a real opportunity to connect people with similar conditions to help alleviate the burden and encourage proactive self-management.

Background: The number of different cushioning materials available nowadays for orthotics is mind-boggling: different grades of EVA, Poron, polyurethanes, gels, polypropylene, polyethylene, Plastazote, silicone rubbers, cork, latex, EPDM, Deleur foam, felt, etc. Each of them works in different way providing varied degree of cushioning, impact protection, energy return or combinations of all of them. They have been on the market for a while and proved to be good orthotic "working horses”. The newest scientific research provides good insight how and why these materials work. However even more exciting are recent postings from material scientists showing how to engineer new materials which don’t have some drawbacks of the traditional orthotic materials and can be purposefully tailored to orthotic applications. The material science started to investigate and mimic ingenious solutions developed already by Nature. Ever wondered how a gecko can walk safely on a ceiling, how horse hoofs protect the animal from breaking its legs even in full gallop or why soft pomelo fruit weighting 6 kg does not break up after falling from 15 m high tree? The secret of these excellent impact protection solutions lies in a specific, hierarchical structures of the natural materials, which are nano- or micro composites consisting of hard and soft domains. The aim of this investigation was to compare the behaviour of traditional orthotic materials to the new engineered ones and assess the opportunities the newcomers bring to bespoke orthotics.

Methods: Several different traditional orthotic materials and new bio-mimicking copolymer nano-composites were tested for the following properties: deceleration of impact force as a measure of impact protection, maximum rebound as a measure of energy returned, speed of rebound, indent under the impact force. These properties were tested for newly manufactured materials and then repeated after up to 500,000 impacts to assess the rate of materials ageing, performance deterioration due to wear and tear and ultimate compression set. The energy of the impact applied to the materials was standardised at 3 joules and the speed of the impact was 2 m/s. Materials’ hardness, density and thickness were also assessed and correlated to the impact testing results.

Results: The research resulted in a good mapping of different orthotic materials, including the new engineered copolymer nano-composites, for their properties important for orthotic applications. The new materials proved to possess a wide range of properties desirable in orthotics like cushioning and/or high energy return, good durability, and lightweight.

Conclusions: The research showed that properties of new orthotic materials can be significantly tailored by purposefully engineering their chemical composition and hierarchical physical morphology. A good knowledge of the relationships between the materials’ structure and their properties enables efficient optimisation of the materials and informed selection of materials for specific needs of any patient. This ultimately can provide patients with best performing bespoke orthotics and quick, reliable service.

Background: There is little published information on how knee gait kinematics vary with BMI. This is because the method of obtaining data uses an optical gait lab, which is expensive and time consuming. Studies that are published focus on joint forces, rather than joint kinematics and have small sample sizes due to the use of the optical lab1. The development of inertial sensors opens the possibility of monitoring large numbers of people in normal surroundings.

Results: Kinematic data for knee range, stance flexion and knee range symmetry, plus temporal stride duration are quoted values. Speed is calculated from other quoted gait parameters and height. The results show that there are no statistically significant differences in any of the gait parameters or speed with BMI (table 1).

Conclusion: It is often assumed that people with a higher BMI adapt their gait when compared to those with a healthy BMI. However, this data on 254 healthy people shows the knee joint moves the same in the sagittal plane, stride duration remains constant and speed doesn’t vary. This isn’t in contradiction to publications referring to joint loading, rather it provides additional, complimentary information. A higher BMI may predispose people to medical conditions such as osteoarthritis of the hip or knee, or may cause the disease to progress more rapidly as the loading on the joints is greater5. However, if the person remains healthy, their knee gait kinematics in the sagittal plane do not alter with BMI.

Background: The foot is commonly affected in rheumatoid arthritis (RA) resulting in pain, walking difficulties and disability. Omission of foot joints from the disease activity score-28 (DAS-28) may lead to underestimation of foot disease and suboptimal medical and non-medical management. The overall objective of this study is to evaluate the measurement properties of the Rheumatoid Arthritis Foot Disease Activity Index-5 (RADAI-F5), a newly developed 5-item (0-10 numerical rating scale) patient-reported outcome measure (PROM) with summary score (0-10) for measuring foot disease activity in people with RA.

Methods: Participants with RA recruited from NHS rheumatology outpatient clinics completed the RADAI-F5, a self-modified Rheumatoid Arthritis Disease Activity Index (mRADAI-5) which is a self-reported measure of global disease activity, the Foot function index (FFI), Foot Impact Scale impairment/footwear (FIS-IF) and activity/participation (FIS-AP) subscales. DAS-28 was also recorded for each participant where possible. Participants completed RADAI-F5 again at 1 week to allow evaluation of 1-week reproducibility. Construct validity was evaluated using Spearman’s rho to test a priori hypotheses for expected strength of associations between the RADAI-F5 and the alternative disease activity and foot—related disability scales at baseline. Internal consistency was evaluated using Cronbach’s alpha. One-week reproducibility was evaluated using the intra-class correlation coefficient (ICC), 90% smallest detectable change (SDC90), and 95% limits of agreement (LOA). Content validity was evaluated using 5-point Likert scales for readability and relevance.

Results: Of 142 respondents, 103 were female and 36 were males with a mean (SD) age of 55 years (12.5) and mean (SD) RA disease duration of 39 months (70.4). Mean (SD, range) RADAI-F5 scores for the sample were 5.02 (2.47, 9.2). Associations were largely consistent with a priori hypotheses for construct validity. Strong associations were observed between the RADAI-F5 and MRADAI-5 (0.789, CI 0.73-0.85), the FFI (0.713, CI 0.62-0.79) and FIS-IS (0.695, CI 0.66-0.82) (p<0.001). Moderately associaitons were observed with the FFI-AP (0.478, p<0.001, CI 0.37-0.63). A weak associations was observed between the RADAI-F5 and the DAS-28 (0.379, p<0.001, CI 0.26-0.57). The RADAI-F5 demonstrated high internal consistency (Cronbach’s Alpha=0.82), and floor and ceiling effects were both absent. The RADAI-F5 demonstrated good reproducibility (ICC=0.868, p<0.001, CI 0.80-0.91) and the value for SDC90 was 2.26. The upper and lower bounds for 95% LOA were -2.57 to 2.80, with 97% of scores observed within these bounds. Content validity was confirmed with 82% and 84% of participants rating the instrument as relevant and easy to understand respectively. The median time for completion was 5 minutes.

Conclusion: The RADAI-F5 is a highly valid and reliable PROM for measuring foot disease activity in RA patients. Furthermore, the RADAI-F5 appears to be feasible for use in clinical practice and can be used as an adjunct to the DAS28 to measure foot disease activity.

Background: Rheumatoid arthritis is a chronic inflammatory arthropathy that affects multiple synovial joints. In recent years the provision of biologic therapy has increased; a drug treatment that has been shown to have significant benefit over previous treatment approaches. However, choosing the best drug or achieving the optimal dose can be problematic. There is anecdotal evidence to suggest that the beneficial effect noted systemically may not be evident in the foot. As such, the aim of this preliminary study was to explore whether signs of disease activity within the forefoot of patients starting biologic therapy could be observed.

Background; Building research capacity is an essential part of sustaining evidence based practice in nursing and allied health professions working within rheumatology. Whilst medical and dental professions have a strong tradition of research capacity building, the situation for Allied Health Professionals and Nursing in the UK is less developed. The aim of this study was to evaluate a collaborative internship programme across five UK universities from 2015-18 (Universities of Southampton, Leeds, Salford, Oxford, the West of England). The internship included an eight-week programme of structured training workshops and research project delivery, and ongoing mentoring by experienced researchers. Sixteen interns were recruited from across the UK, including physiotherapists (7), podiatrists (5), occupational therapists (2) and nurses (2).

Methods: The evaluation employed mixed methods including: analysis of research metrics, an annual evaluation questionnaire sent to all 16 interns, and qualitative email interviews (12 interns, 13 mentors) conducted at the end of the internship programme. Interpretive phenomenological analysis of transcripts was used to identify recurring themes.

Results: Early quantitative outcomes from internship projects include three peer-reviewed publications, and 21 conference abstract presentations. Interns reported positive changes in their perceptions of research and rheumatology, including a realisation that clinical academic pathways were possible. Skills attained of most value to interns were technical research (e.g. qualitative research), research process (e.g. securing funding), rheumatology knowledge (e.g. fatigue), and general skills (e.g. communication). Two domains of impact were identified. First, the programme directly impacted on research careers with four interns securing clinical academic positions and most others reporting commitment to pursuing active research in the near future. Second, the internship had an impact on practice for those entering full-time clinical careers. Interns spoke of their ability to be ‘critically aware’, seeking an evidence base for clinical decisions. Many spoke of a new confidence in expressing opinions with clinical colleagues. Others spoke of the need for patient-centred care, learned from the Patient and Public Involvement training provided by the internship. Similarly, interns reported an increased awareness of the wider relevance of rheumatology, which influenced their subsequent clinical practice. One challenge for the internship programme identified by mentors was the difficulty in attracting interns from all Allied Health Professionals and Nursing backgrounds (notably nurses). In addition, several interns entering full-time clinical roles reported difficulties in continuing research in environments that devalued such activity.

Conclusion: The collaborative internship programme has been successful in supporting research capacity building by introducing newly qualified allied health professionals and nurses to research and rheumatology. This has generated tangible benefits through research outputs, clinical academic careers and influencing clinical practice. The programme has been successfully renewed for a further three years from 2018-2021 and is being informed by the evaluation findings. It has now been extended to include all UK AHP professionals (Health and Care Professions Council registerable) and nurses. Additionally, two new HEIs (Glasgow Caledonian and Keele Universities) have joined the national consortium. The programme serves as a model for research capacity building for other health conditions and professions.

Background: There has been an increase in the demand for foot and ankle assessment in the specialist orthopaedic hospital. Waiting times have been increasing over the past few years and there is need to reduce this. Podiatrists to work in an extended scope practice role at the specialist orthopaedic hospital have been used to create new patient assessment slots to help with this increased demand. The podiatrists undertake the first level of paper triage and help to triage (Face- to-Face) and assess the new patient’s that come through the foot and ankle team. The main objective of the introduction of this clinic was to reduce the waiting times for new foot and ankle patients that were referred into the hospital. This would be reviewed constantly and would help inform as to if the clinic should be made permanent after the pilot phase (6 months).

Methods: The use of Podiatrists in foot and ankle clinics is not new (Walsh et al, 2014) however the use of Podiatrists employed by ‘tertiary’ specialist orthopaedic hospital is not well documented. The podiatrists would see the patients in new standalone clinics as they work within the consultant lead foot and ankle clinics and undertake new patient assessments, undertake treatment plans reviews, see post-operative patients and discharge patients by offering autonomous care. The innovate element of this service review is to promote the effectiveness of podiatrists who work in an extended role at reducing waiting times.

Results: 495 patients have seen in the 21 months from April 2017 to December 2018. 224 patients (45%) seen in the triage foot and ankle clinics have been discharged at the first appointment. 27 (6%) were referred onto surgical intervention, of which 92% went on to have surgery, and 132 patients were reviewed for clinical case discussion with the consultant but were not surgical cases. The waits for the foot and ankle clinics were reduced from 17 weeks to 11 weeks by the introduction of the 3 new weekly clinics.

Conclusion: The Stand-alone Foot and ankle triage clinics have been an effective way in reducing the waiting times to be seen by the consultant foot and ankle surgeon. The waits have reduced on average by 6 weeks. The new clinics have provided assessment at an earlier stage and have helped to divert non-surgical cases away from the consultant and get appropriate treatment. Treatment can be started at the first appointment. This shows that the use of appropriately skilled and experienced Podiatrists can help to improve orthopaedic care and can help to create a career pathway for Podiatrists.

Background: The aim of this review was to evaluate and summarise the current evidence on non-computerised or non-recorded real time adult gait assessment conducted within the clinical musculoskeletal setting. It was hoped a protocol for best practice and a framework for further research could be developed from this search.

Methods: Can a protocol for best practice and a framework for further research be established from previous literature relating to non-computerised or non-recorded real time adult gait analysis in a musculoskeletal clinical setting.

Results: The review found no significantly informative papers relating to the search.

Conclusion: The lack of research on the accuracy, reliability and therefore worth of this highly recommended area of musculoskeletal assessment raises concerns over current assessment and treatment pathways. Further work to develop a method by which gait analysis can be routinely employed in musculoskeletal clinics as a diagnostic tool is required, with any new approach undertaking robust methodological testing.

Background Stresses on the feet and lower body during prolonged walking or standing can lead to musculoskeletal (MSK) pain and discomfort. A range of six orthotic insoles has been developed to provide unique support, shock absorption, cushioning and pressure re-distribution to various aspects of the plantar surface of the foot in order to treat a variety of lower body musculoskeletal pain related to mechanical stresses. The aim of this clinical trial was to evaluate the effects of foot orthosis adjustment by this range of insoles (full length insole, ¾ length, arch support, heel cup) by measuring their biomechanical impact under the plantar surface in healthy volunteers.

Methods: This was a single centre, randomised, open-label, cross-over study evaluating 24 healthy subjects. On a single day, subjects were asked to walk at a self-selected speed during seven conditions (wearing standard shoes alone and six investigational orthotic insoles), which were randomised. In-shoe pressure (F-Scan) and force data were measured to assess shock absorption properties, loading pattern and stability/balance of each insole design versus standard shoes alone.

Results: A total of 24 participants were randomised (11 men, 13 women). The mean age was 36.1 years (range: 20 to 55), mean height was 1.695±0.0914 meters, overall mean body weight was 63.63±10.117 kg, and mean BMI was 22.03±2.022 kg/m2. In-shoe dynamic pressure was measured in 23 subjects. Pressure change and pressure time interval measurements were variable between insoles and anatomical areas of interest (ball of foot, medial arch, heel), which was expected given the differing designs of the insoles. Heel peak pressure was reduced across all insoles; a statistically significant reduction was observed in both feet for 4 of the 6 insole designs tested. The most significant changes in pressure time integral were noted in the medial arch area for 5 of the 6 insoles. Furthermore, a decrease in the force time integral was observed in all insoles with statistically significant results observed in either one or both feet. Contact area for the sole and medial arch significantly increased in either one or both feet, for all but one insole tested. No adverse events, adverse device effects or device deficiencies occurred during this clinical investigation.

Conclusions: This study has aided in further understanding the biomechanical impact and mode of action of each orthotic design. Insoles with heel cups and medial arch geometries consistently affected peak pressure, pressure time integral and contact area data, conferring a beneficial impact on shock absorption, loading pattern and stability which has the potential to be associated with clinical benefit. A subsequent clinical investigation to evaluate the efficacy of these insoles on specific areas of lower body MSK pain is underway.

Background: Musculoskeletal (MSK) lower body pain can be caused by long periods of walking or standing and often goes undiagnosed and untreated. The aim of this study was to generate evidence regarding the severity and distribution of self-reported lower body pain in a working population on their feet most of the day and suffering from non-diagnosed pain.

Methods: The study was conducted online with a UK sample. Participants with self-reported work-related lower body MSK pain completed the Brief Pain Inventory (BPI), the Work Productivity and Activity Impairment (WPAI) scale, and a quality of life instrument, the AQoL-4D. Information regarding sociodemographics and work patterns was also collected. Statistical analysis was carried out using analysis of variance to assess group differences, and multiple linear regression to explore the impact of BPI on absenteeism/presenteeism.

Results: A total of 1035 participants completed the study (57% females). The average age of participants was 43.4 years (18 to 67 years). The majority of participants resided in Scotland (53%) and England (43%). The largest number of participants worked in healthcare (17%) followed by hospital / leisure industry (13%). A large number of participants (60%) had 8+ hour shifts and were on their feet either most or all of the time (78%). Pain was reported most frequently after each shift (27%). Mean pain severity and interference were 4.63 (standard deviation, SD: 2.07) and 4.37 (SD: 2.49) respectively. Mean overall AQoL-4D scores were 0.631 (95% confidence interval, CI: 0.609 to 0.653). The mean number of working hours lost due to MSK pain was 4.12 (SD: 9.93) in those participants who had worked in the previous 7 days; absenteeism and presenteeism due to pain were 10% (SD: 21%) and 33% (SD:25%) respectively. There was strong statistically significant association between the pain measures and absenteeism/presenteeism (p<0.0001).

Conclusions: Musculoskeletal lower body pain is highly prevalent in those who spend most of their working day on their feet. This type of pain impacts significantly on their quality of life and productivity at work and has a potential economic impact through lost work and presenteeism.

Background: The Achilles tendon (AT) is an important structure in lower limb function as one of the prime movers during sagittal plane motion. The AT can be pathologically affected by diabetes resulting in reduced function. Musculoskeletal ultrasound (MUS) has been shown to be a reliable, sensitive and specific imaging modality for visualising changes in the AT in healthy volunteers. However, there are few studies detailing the efficacy of using MUS in people with diabetes. The aim of this review was to identify literature related to the use of MUS to image the AT in a) healthy populations and b) those with diabetes.

Methods: A PICO (population, intervention/indicator, comparison, outcome) approach was used to define a structured search strategy which included: policy, protocol, proce*, guide*, recommendation*, standard*, technique*, method* pract?e, diabet*, Achilles, “calcaneal tendon”, “tendo calcaneus”, ultraso*. The databases searched were Amed, Cinahl, Cochrane, Pubmed, Scopus and Web of Science from the year 2000 to 2019.

Results: Of the 13 published works, 2 were guidance documents (a guideline and a protocol) and the remaining 11 publications reported the reliability of MUS in people with diabetes (n=4) and without (n=7).The guideline document recommended the foot be placed in prone hanging position with AT measurement in the transverse planes only but does not give justification for this. The protocol document recommended inclusion of evaluation of the contra-lateral limb for comparative purposes and the use of Doppler to measure neovascularisation of the AT. It also recommends AT measurement at 2cm calibration points from the enthesis but does not give justification for this. There was no current literature identified that detailed an optimal MUS protocol to visualise the AT in people with diabetes. Overall, the approach to use of MUS to evaluate the AT in people with and without diabetes varied between studies, lacked reliability testing and reported a range in measurements (0.41-5.2mm).

Conclusion: Further work on consensus and reliability is required in this area to establish MUS as an adequate imaging modality for the evaluation of the AT in pathological groups such as diabetes.

Background: In 2014 The Scottish Foot Action group completed an inpatient audit of patients with diabetes and found that 2.4% had not had their feet checked for risk of ulceration. A follow up campaign called Check, Protect, Refer (CPR for feet) was implemented to raise awareness of the importance of early referral to the MDT/Podiatry team. There was no method available at the time to measure the impact of the campaign on reducing iatrogenic harm. The purpose of this project was to implement a model for improvement which would focus on 3 key areas; Risk assessment on admission, application of pressure redistribution products and immediate referral to podiatry (NICE 2016). A robust method for incidence reporting, supportive peer review and data analysis was designed and implemented from 1st June 2018.

Method: The project included 280 wards within NHSGGC. Each ward was provided with information and support of the new system for incidence reporting. The datix system used 8 data entries to determine if the reported incident was avoidable or unavoidable pressure damage. The data was collected and analysed to identify hot spots (areas of 2 or more avoidable incidents within a ward). An action plan and a supportive learning & education plan was put initiated to reduce the potential for future incidents. Further work was done to support the use of pressure redistribution products and mattresses. All wards were provided with information on how to electronically refer to podiatry.

Conclusion: Although the project is still in its infancy the results after a short period of time are encouraging in demonstrating the impact of applying a robust model of reporting. Developing a positive culture of support has also been of benefit to ward staff by providing a safe and supportive environment for learning and education. This helps to use the learning to prevent future incidents. Investing in the resource to support a prevention model of podiatry care has been shown to be of benefit to the reduction of patient harm and may also bring a cost benefit to the health board.

Background: AF is a heart condition that commonly displays no symptoms. Without treatment those living with AF are at increased risk of a stroke costing the NHS on average £23,315 per patient. Patients with diabetes have their pulse checked as part of their annual foot check review to detect the presence or absence of a foot pulse to prevent diabetes complications. The aim of this study is to increase the diagnosis of AF using foot pulse checking during patients diabetes annual foot review.

Methods: A three-month pilot (January 2016 – March 2016) was conducted by County Durham and Darlington NHS Foundation Trust and has been part of a wider AF Programme run by the Academic Health Science Network for the North East and North Cumbria (AHSN NENC) in conjunction with the Northern England Clinical Networks. During the initiative, 45 podiatrists were trained to spot heart irregularities, using a Doppler. Any person detected with an irregular pulse was referred to their GP for a 12-lead ECG to confirm diagnosis.

Results: 5,000 diabetic patients had their feet pulse-tested. 10 patients with previously unknown AF were detected, indicating that one new case of AF could be identified for every 500 patients. With 1 in 20 patients, either untreated or inappropriately treated, having an AF-related stroke, two patients each year would be prevented from having an AF-related stroke.

Conclusions: The pilot has been so successful that the work continues in County Durham and Darlington, and is being spread locally via the Northern Diabetes Footcare Network. If all patients with diabetes, in England, had their pulse checked as part of the annual review screening for an irregular pulse 6800 people could be detected with AF. If all these people were correctly anticoagulated, 340 AF-related strokes could be prevented as well as saving the NHS £7.9M.

Background: Following a review of existing literature, no research had been conducted to determine an appropriate length of time needed to screen a pulse for Atrial Fibrillation (AF) with a doppler. Developments to the understanding of this could contribute to a more effective screening process in podiatry to increase the likelihood of early detection reducing the risk of strokes.

Results: Overall, the intra-rater reliability was found to be excellent. There were similar score agreements between ratings producing a strong-positive ICC linear relationship of +0.70. The distribution of results of 65% of the data within the first 10-seconds and 29% of data between 10 and 20-seconds were also noted. These findings show it is possible for a podiatrist to distinguish an AF pulse with a doppler within 20-seconds, 94% of the time. Hypothetically a lengthier time spent on a pulse will ensure quality and consistency in AF detection and consequently reduce risks of AF. All subjects were known to have pre-diagnosed AF by the single-rater, consequently it is recognised that rater-bias could have impacted the data’s validity. This problem often arises when a single-rater acts on behalf of the population. A limitation of this study is human error caused by a delay in the raters reaction time when stopping the stopwatch. This potentially effected the results accuracy, although it is also argued a single-rater will cancel out the overall human error. It is recommended for future research that a larger and a more varied sample is recruited for a blind Randomised Control Trial with a control group of patients with normal sinus rhythm and multiple-raters. This is to eliminate the possibility of rater-bias and to measure inter-rater reliability if variables between raters can be controlled and standardised training for raters received.

Conclusion: In conclusion, this primary research contributes to existing knowledge of AF by providing a deeper understanding of the AF screening process in a podiatry setting. This research established that AF detection using a doppler can be achieved in an efficient and practical time within a minimum of 20-seconds and can be feasibly achieved while performing routine podiatry examinations.

Background: Diabetic foot ulcerations (DFU) are consistently considered a chronic wound with increased risk of amputation, infection, suffering and death. It is well established that reducing pressure from the DFU site allows the foot ulcer or damaged tissues to heal. Patient quality of life (QOL) has also been shown to be significantly reduced in diabetic patients with foot ulcerations has compared the physical, emotional and financial impact of DFU as worse than some cancers. The healing of DFU is therefore paramount to avoiding such devastating disease outcomes including amputations, poorer QOL and increased financial burden for the patient and the providing health service. The aim of this study was to provide proof of concept of the effectiveness of a newly designed offloading boot, compared to usual stand of care (USC). Secondary factors related to QOL and patient related factors of using a new device were also explored.

Results: Twelve patients were recruited, (Female 1, Male 11), with a mean age of 65.1years (SD 15.7), diabetes duration of 17 years (SD=13), BMI of 19.5 (SD=6), ulcer duration of 29 weeks (SD=32.1). While there was a difference in the pattern of PTI between the PulseFlow DF and the participant’s USC at the medial forefoot (t=-1.6, p=0.1, 95% CI = - 31.4 to 5.2) and the lateral forefoot (t=-1.3, p=0.2, 95% CI = -24.3 to 6.7), these were not significant.

Conclusions: The PulseFlow DF boot alters the PTI in people with diabetic foot ulcers however there is insufficient evidence to suggest it is better than usual standard of care. The use of patient involvement via a questionnaire presented interesting findings i.e. the device was generally acceptable however the lowest median scores related to the device being heavier than expected. This allowed an insight into the use of this new design alongside the aims of the study. However due to the few completed questionnaires (Number=12, fully completed=10) no real statistical analysis can offer strong conclusions. While no difference was found in PTI in the forefoot this could be associated with our small sample size. Further research is required, in the authors' opinion, preferably using a randomised controlled trial using: Primary Aims Time to healing the DFU and Secondary Aims Cost value analysis, Patient involvement in acceptance and time used and Time remained healed.

Background: Negative Pressure Wound Therapy (NPWT) is one of four advanced therapies being investigated in the NIHR HTA funded MIDFUT study, which is looking at the treatment of hard-to-heal diabetic foot ulcers (DFUs). The trial eligibility criteria enables the use of NPWT on a range of wound types which may not always be considered for NPWT in standard practice.

Methods: Through practical workshops and discussion of interactive simulated patient case studies in an open forum we have identified and addressed the following considerations for the application of NPWT and potential benefits for this patient group.

Conclusion: Through close liaison with clinicians and successful training workshops we have developed guidance for the use of NPWT in a chronic hard-to-heal DFU population which may not previously have been considered to receive this intervention. This guidance is discussed with participating centres in detail at the site initiation visit and intervention training sessions to enable development of NPWT application skills and ensure all eligible patients have the opportunity to take part in research.

Background: The National Institute for Health Research in partnership with Health Education England provide funded opportunities for Podiatrists to learn about research whilst continuing to develop their clinical practice.

Methods: There is a range of educational funding streams available for podiatrists of all backgrounds, ranging from internships for those who are perhaps newly qualified through to post-doctoral awards for those more experienced in research. Podiatrists at all clinical levels with an ambition to make improvements to the service they provide are able to learn about how to challenge convention or discover new solutions through these awards. However, identifying the right opportunity for the individual or navigating the application process can be daunting.

Conclusion: HEE/NIHR offer a range of training opportunities for Podiatrists to get involved in research and improvement. The Advocates are experienced in supporting people or teams to identify and apply for funding.

Background: Pressure ulcers are a key indicator of the quality and experience of patient care. 700,000 people are affected by pressure ulcers each year. Treating pressure ulcers costs the NHS more than £3.8 million every day. Many pressure ulcers are preventable, and when they do occur they can have a profound impact on the overall wellbeing of patients, and can be both painful and debilitating. Heel ulcers are one of the most challenging areas of pressure ulcer management, as not only are they the second most common site for pressure ulceration, they can sit alongside other complicated conditions which affect the feet, such as diabetes and peripheral vascular disease. This can make them both confusing and difficult to diagnose and treat.

Methods: The PDSA took place across two hospital sites, focusing on four Elderly Medical Wards and included increasing staff education, suportive visual aids, increased provision of offloading devices on wards, and promotion of shared care between patients and staff. This was a collaborative approach with representatives from podiatry, tissue viability and patient safety teams.

Results: The project findings were not what the team expected. Numbers did not reduce significantly over six months and only small changes were identified in reduction of heel ulcers, partly because numbers were relatively small to begin with. However, the team felt that the impact which came about from other aspects of the project were just as important.

Conclusion: Increased staff knowledge and awareness around heel pressure damage, patient empowerment to help reduce their own risks of pressure ulcers, significantly quicker time from identification of problem to treatment for patients through earlier detection and the set up of electronic referrals to podiatry, improved accuracy of pressure ulcer categorisation, 100% reduction in misuse of softcasts by ward staff and more joined up collaborative working between the podiatry, tissue viability and patient safety teams.

Background: Type 2 diabetes mellitus (T2DM) is one of the fastest growing non-communicable diseases worldwide and its prevalence is increasing rapidly around the world parallel to increase in the obesity. Foot ulcers, infections, and deformity are some of the major sources of mortality and morbidity among the population with type 2 diabetes mellitus. Assessment of protective sensation using Smith Weinstein 10g monofilament is part of routine clinical practice. However, there is no objective method of measuring protective sensation in people with diabetic peripheral neuropathy. Therefore, the objective of the study is to determine the normative values for protective sensation of foot using Neurotouch device in Indian Population.

Methods: After obtaining institutional ethics committee clearance and informed consent, the detailed foot assessment was conducted on 390 healthy participants using NEURO TOUCH device, which incorporates Monofilament, Vibration perception threshold, Hot and cold perception and Infrared thermometry in a single handheld battery-operated instrument. The protective sensation was measured using monofilament module of Neurotouch which shows objective reading of the protective sensation measured in grams(gms).The data was statistically analyzed.

Conclusion: In the present study, we established the normative values for protective sensation of foot in healthy individuals using Neurotouch device. The present study concluded that the normative values for protective sensation is found to be in the range of 10-20grams and provides a substantial evidence to stratify the people with diabetic neuropathy based on monofilament readings using Neurotouch device.

Results: The project lead to a dramatic reduction in inappropriate referrals and streamlined demand. As a result, capacity has been closely matched to true demand allowing us to respond quickly to high risk patients requiring a visit within 48 hours. Pre transformation in 2016, 1349 patients out of a caseload of 2217 were overdue. The longest wait time being 65 weeks.

Conclusion: Plans for the sustainability of this work include, audit of service standards for high risk patients to ensure they are seen within 48 hours of referral and maintain zero waits for all follow up patients. To audit the effectiveness of seeing all patients on time against re-ulceration rates for high risk wound patients. Increase clinical supervision of Band 5 and 6 home visit podiatrists to increase wound care knowledge and to ensure quality and safety of all patients.

Background: This report aims to demonstrate how a podiatry service quality improvement project into a residential care home was implemented and why it was needed. Risk of foot ulceration increases in those with age, neuropathy, peripheral vascular disease and immobility. In 2013 the Sunderland Care Commissioning Group piloted, through the readmission scheme, a podiatry service providing specialist care into 11 care homes in the Coalfield’s locality of Sunderland, which are a mixture of both nursing and residential homes. The service provides, foot care for all residents and prevention strategies for those classed at risk of developing foot ulceration and to provide specialist wound care interventions for residents presenting with foot ulcers into each care home in the Coalfield’s locality. There are financial constraints to rolling out the Coalfield’s model to the further 36 care homes in Sunderland. Therefore, a new model was explored. This is a high-risk model only, piloted in one care home.

Methodology: Driver diagram was used to define key problems, activities required to deliver improvement. Fish bone diagram was used to establish the route cause analysis. The plan do study act (PDSA) cycles were used to pilot the interventions at the study site to ensure effective small change The Comb-B Behaviour Change Wheel was also included to ensure that interventions undertaken were sustainable by identifying the behavioural change required.

Results: There were no pressure injuries identified at post-intervention, this was a significant improvement from baseline. Staff had referred three grade 1 pressure injuries and one foreign body, one foot pain and two trauma ulcers during the intervention, showing a 300% increase in reported grade 1 pressure injuries.

Conclusion: This quality improvement project has demonstrated a person centred, evidence based, older person service delivery for sustainable future that embeds a multi-disciplinary team to the high-risk podiatry model of service. It has shown that behavioural change has occurred with small change interventions. It has used the robust methodology of PDSA to effect this change and allow for a clear report to be able to articulate the benefit.

Background: The stratum corneum is the uppermost layer of the epidermis and is covered by a thin layer of sweat, sebum and epidermal lipids that are collectively called the 'acid mantle'. The low pH (between 4 and 7) of this surface contributes to the integrity of the stratum corneum, reduces permeability and reduces proliferation of potentially hazardous micro-organisms on the skin surface. The pH of skin on the foot is poorly understood but the limited information we do have suggests that the foot skin surface is significantly different to the rest of the body.

Method: 28 healthy participants with no history of foot skin pathology were recruited to have the skin pH measured at nine different locations on the foot using a glass electrode pH probe (Dermalab Combo, Cortex, Hadsund, Denmark).

Results: Statistically significant differences were found between the skin surface pH at different sites on the foot. The pH measurements were significantly less acidic on the plantar skin sites (median: 5.61) compared to the dorsal sites (5.02, P<0.001). The plantar surface medial longitudinal arch, however, displayed a pH measurement more comparable to the dorsal surface measurements.

Conclusion: Further investigation is required to explore the significance of these data in regards to the immune and barrier function of the skin at these different locations.

Background: ‘Health and Wellbeing 2026; delivering together’ advocates an approach to achieving better outcomes for individuals and populations. It is well documented within this framework that to achieve this we need to continuously improve on the quality and safety of care. Clinically for podiatry, this means ensuring patients are assessed in a timely and appropriate way in line with regional and national guidelines and thus this ‘basic’ information directly impacts on the provision of care for our service users and the delivery of our service. Ultimately the basics are important to ensure safe practice, standardised care, and to formulate treatment plans tailored to the individual’s needs, to ensure assessment of our patients is meeting current regional and national guidelines and professional accountability.

Methods: To determine if a patient meets the podiatry service access criteria an assessment of the individual’s risk status is required. This also helps us identify the patients RISK of developing potentially limb-threatening foot complications. This information is also vital for audit, future workforce planning and capacity management our service. To carry out this project we used the model for improvement framework. Our Health and Social Care Trust's community podiatry service is based in 6 clinical locations, all providing a service in the clinical and domiciliary setting. A random sample was identified from each setting using random.org. The information for 60 patients was selected, 10 from each location.

Results: From our sample, 100% of assessments and risk assessments were open of our 60 patients but only 60% had been risk assessed within a 12 month period. So whilst everyone had been risk assessed our guidelines state that this should be completed again within a 12 month period so we are falling below our target of 100%. We found 73% of vascular assessments from our sample of 60 have been completed within the recommended 12 month period and 70% of the neurological assessments were completed within the 12 month period. Staff (n=70) were surveyed using a questionnaire, to see if we could identify reasons why the completion of assessments and assigning of risk. 15 of those surveyed responded all stated they understood the importance of completing assessments and assigning risk. Barriers identified to doing this included time constraints, unaware that assessments had to be completed within 12 months and some of the tabs on the electronic record system were deemed not to be user-friendly.

Background: This service quality improvement project aimed to develop an offloading pathway to ensure timely, consistent and appropriate offloading therapy for foot ulceration in our Health and Social Care Trust (HSCT). It is well established that neuropathy, deformity and trauma are the most common causes of Diabetic Foot Ulceration (DFU). Evidence is clear that adequate off-loading increases the likelihood of DFU healing and that increased clinician use of effective off-loading is necessary. However recent surveys show a large discrepancy between guidelines and clinical practice in off-loading diabetic foot ulcers.

Methods: An audit was conducted in 2015 of offloading carried out within the high-risk patient group in BHSCT, and this had indicated that offloading was not being optimised - 43% of patients had been offloaded v 57% who were not offloaded. This clearly highlighted variations in clinical practice. Using the PDSA cycle as our model a questionnaire was devised to determine if staff had the relevant baseline knowledge expected prior to implementing a new pathway. Following analysis of the audit findings training on offloading was provided for all staff in both hospital and community services and a further questionnaire administered post this.

Results: The results showed that the training provided had increased staff knowledge and confidence in providing various offloading devices for high-risk patients. We recognise that training needs to be ongoing to ensure offloading is embedded in clinical practice. We then developed an offloading pathway document, using the Welsh National Plantar Ulceration Off Loading Pathway 7as a model. This first draft is now ready for consultation. Following consultation, there will be a rollout and implementation of the new pathway, followed in time by an audit to assess adherence.

Methods: Data was collected from UK-based podiatrists, physiotherapists, and orthotists with experience of managing foot problems in children. Data was collected via a self-administered online survey and data was captured over a four-month period from July – October 2018. The project was approved by the institutional ethics panel and all participants provided informed consent.

Results: Fifty-five participants completed the survey: 33 physiotherapists, 16 podiatrists, and 6 orthotists. The results revealed that assessment techniques varied between professions with standing tip-toe (podiatrists - 62.5%; physiotherapists - 51.5%; orthotists – 66.7%) and joint range of motion (podiatrists - 68.8%; physiotherapists - 36.4%; orthotists - 83.3%) being the most commonly used. Professionals reported using a diverse range of interventions. Forty percent of all respondents used orthoses (pre-fabricated or custom) as a first-line intervention; podiatrists tended to use prefabricated orthoses (81%). There and there were no statistically significant differences between professions (p = 0.07). Sixty-three percent of respondents reported that resolution of symptoms was the key marker for withdrawal of intervention but acknowledged that the decision-making process was complex. Use of child-specific, standardised measures to evaluate outcomes in practice was variable.

Conclusion: These results illustrate inconsistencies between allied health professionals with respect to assessment, management, and outcome measurement for symptomatic paediatric pes planus. These findings might be explained by the lack of robust evidence to guide practice and suggest a need for further work to harmonise assessment and treatment approaches between professions. Addressing these discrepancies could help prioritise professional roles in this area, and better support the management of these children through evidence-based, cost-effective interventions.

Background: Pes planus have been described as one of the most common conditions seen in paediatric practice (1,2) and the most common reason for attending paediatric orthopaedic clinics (3) but questions remain about the most effective treatment modality, or whether treatment is even necessary. The aim of this study is to evaluate the clinical and cost-effectiveness of custom-made and prefabricated orthoses in addition to exercise and advice, compared with exercise and advice alone on the physical functioning of children with symptomatic pes planus.

Methods: OSTRICH is a multi-centre, three-armed, pragmatic, individually randomised, controlled trial. It includes an internal pilot, economic and process evaluation and qualitative study. We plan to open 30 recruiting sites from any primary or secondary care NHS outpatient clinic providing care for children with pes planus. We will recruit 1085 children/young people aged between six and 16 years, who have symptomatic pes planus. Participants will be excluded from the trial if there is a history of major trauma to the lower limb; pes planus of non-idiopathic cause or symptoms secondary to any systematic condition/syndrome/malignancy; have a history of foot and/or ankle surgery or require an ankle-foot orthoses or other lower limb device.

Results: The internal pilot study will include qualitative interviews with children and parents and clinicians to highlight any barriers or facilitators to recruitment of trial participants. Treatment fidelity will be assessed using the following methods: 30 observations of participating clinicians; case report forms; patient reported adherence and interviews with trial participants to determine the acceptability of the intervention. Our implementation strategy will be informed through two focus groups with participating clinicians which will discuss possible barriers and facilitators to implementing our findings in routine practice.