Musculoskeletal foot problems in primary care: what influences older people to consult?

´Feet are second class citizens`: exploring the perceptions of Scottish and Portuguese older adults about feet, falls and exercise- a qualitative study

Introduction

Foot problems are likely to contribute to falls risk in older adults. Foot and ankle exercises may be beneficial, but uptake may be influenced by cultural factors. Few studies have explored the views of older adults from different cultural backgrounds about foot-specific falls risk factors, and foot and ankle falls prevention exercises.

Objectives

To explore the views of Scottish and Portuguese community-dwelling older adults who have experienced a fall, about any foot risk factors for falls, and foot and ankle exercises.

Methods

Cross-cultural qualitative study with (n = 6) focus groups exploring the perceptions of Scottish (n = 10, mean age 76 yrs) and Portuguese older adults (n = 14, mean age 66 years) aged, applying thematic analysis.

Results

One main theme `evolving awareness about feet and falls prevention´ and three subthemes; (i) Feet are often forgotten, (ii) the important role of footwear, (iii) need to look at my feet and do the exercises were identified. Scottish participants had more experience of falls prevention but there was a lack of knowledge surrounding foot-specific falls risk factors, and the role of ankle and foot exercise in the prevention of falls. Portuguese participants exhibited a fatalistic approach to falls.

Conclusions

Older adults from both nations had little knowledge of foot-specific falls risk factors, being initially unaware of the functional status of their feet and of the role of exercise in foot care and falls management. There were differences between national groups that should be accounted for when developing culturally adequate interventions.

Prevalence of Foot Pain Across an International Consortium of Population-Based Cohorts

Objective

Despite the potential burden of foot pain, some of the most fundamental epidemiologic questions surrounding the foot remain poorly explored. The prevalence of foot pain has proven to be difficult to compare across existing studies due to variations in case definitions. The objective of this study was to investigate the prevalence of foot pain in several international population‐based cohorts using original data and to explore differences in the case definitions used.

Methods

Foot pain variables were examined in 5 cohorts: the Chingford 1000 Women Study, the Johnston County Osteoarthritis Project, the Framingham Foot Study, the Clinical Assessment Study of the Foot, and the North West Adelaide Health Study. One question about foot pain was chosen from each cohort based on its similarity to the American College of Rheumatology pain question.

Results

The precise definition of foot pain varied between the cohorts. The prevalence of foot pain ranged from 13% to 36% and was lowest in the cohort in which the case definition specific to pain was used, compared to the 4 remaining cohorts in which a definition included components of pain, aching, or stiffness. Foot pain was generally more prevalent in women and obese individuals and generally increased with age, with the prevalence being much lower in younger participants (ages 20–44 years).

Conclusion

Foot pain is common and is associated with female sex, older age, and obesity. Estimates of the prevalence of foot pain are likely to be affected by the case definition used. Therefore, in future population studies, the use of consistent measures of data collection must be considered.

Encounters for foot and ankle pain in UK primary care: a population-based cohort study of CPRD data

Background

Older patients who have foot pain report variation in access to services to manage their foot health. To plan services it is essential to understand the scale and burden of foot pain that exists for GPs.

Aim

To provide UK-wide population-level data of the frequency of foot and/or ankle pain encounters recorded in general practice.

Design and setting

Population-based cohort design study using data drawn from the UK Clinical Practice Research Datalink (CPRD) from January 2010 to December 2013.

Method

All CPRD data were collected prospectively by participating GPs. The primary outcome was prevalence of GP encounters for foot and/or ankle pain, stratified by age, sex, and different subgroups of causes.

Results

A foot and/or ankle pain encounter was recorded for 346 067 patients, and there was a total of 567 095 recorded encounters (mean per person 1.6, standard deviation [SD] 1.3). The prevalence of recorded encounters of foot and/or ankle pain was 2980 per 100 000 (3%). The number of patients with a recorded encounter of foot and/or ankle pain was 1820 per 100 000 (1.8%). Foot and/or ankle pain encounters were reported across all age groups (54.4% females), with those aged 71–80 years placing the greatest burden on GPs. The most common specified referrals were to orthopaedics (n = 36 881) and physiotherapy (n = 33 987), followed by podiatry (n = 25 980).

Conclusion

The burden of foot and/or ankle pain encounters recorded by GPs is not insubstantial, and spans all ages, with a high proportion of referrals to orthopaedics. The authors recommend further exploration of ‘first-contact practitioners’ for foot and/or ankle pain in general practice to alleviate the burden on GPs.

UK podiatrists' experiences of podiatry services for people living with arthritis: a qualitative investigation

Background

Provision of podiatry services, like other therapies in the UK, is an area that lacks guidance by the National Institute for Health and Care Excellence. Many individuals living with arthritis in the UK are not eligible to access NHS podiatry services. The primary aim of this investigation was to understand the views of podiatry clinicians on their experiences of referral, access, provision and treatment for foot problems for patients who have arthritis.

Methods

Focus groups were undertaken to explore, in-depth, individual views of podiatrists working in the UK to gain feedback on experiences of barriers and facilitators to referral, access, provision and treatment for foot problems for individuals living with arthritis. A purposive sampling strategy was adopted and two, semi-structured, focus group interviews conducted, involving 12 podiatrists from both NHS and independent sectors. To account for geographical variations one focus group took place in each of 2 predetermined ‘zones’ of the UK; Yorkshire and Hampshire. Thematic analysis was employed to identify key meanings and report patterns within the data.

Results

The key themes derived from the podiatry clinician focus groups suggest a variety of factors influencing demand for, and burden of, foot pain within the UK. Participants expressed frustration on having a service that accepts and treats patients according to their condition, rather than their complaint. Additionally, concern was conveyed over variations in the understanding of stakeholders’ views of what podiatry is and what podiatrists aim to achieve for patients.

Conclusion

Podiatrists interviewed believed that many individuals living with arthritis in the UK are not eligible to access NHS podiatry services and that this may be, in part, due to confusion over what is known about podiatry and access criteria. Essentially, podiatrists interviewed called for a timely renaissance of current systems, to newer models of care that meet the foot care needs of individual patients’ circumstances and incorporate national multi-disciplinary guidance. Through this project, we have formulated key recommendations that are directed towards improving what other stakeholders (including GPs, commissioners and users of podiatry services) know about the effectiveness of podiatry and also to futureproof the profession of podiatry.

Musculoskeletal Disorders as Common Problems among Iranian Nurses: A Systematic Review and Meta-analysis Study

BACKGROUND

Considering the importance of musculoskeletal disorders (MSDs) as one of the health consequences of job stress among nurses and significant contradictions in prevalence in different parts of the body, this study was carried out to determine the prevalence of MSDs among Iranian nurses.

METHODS

All published studies from June 2000 until June 2015 were considered in reliable databases such as PubMed, Google Scholar, Google search, Scopus, ScienceDirect, and Persian databases such as SID, Iran Medex, and Magiran. These studies, after quality control, were entered into meta-analysis using the random effects model, a total of 41 papers were assessed between 2004 and 2015.

RESULTS

The prevalence rate of these disorders was 60.98%, 47.76%, 46.53%, 44.64%, 42.8%, 36.8%, 24.61%, and 17.5%, respectively, obtained for the back, neck, knees, upper back, ankles, shoulders, hands, hips, thighs, and elbows. Prevalence of MSDs will lead to high costs of medical, absenteeism from work, or even unemployment.

CONCLUSIONS

Due to high prevalence of these disorders among Iranian nurses, providing effective training in the field of ergonomics and undergoing appropriate exercises are necessary to control it.

Evidence for current recommendations concerning the management of foot health for people with chronic long-term conditions: a systematic review

BACKGROUND

Research focusing on management of foot health has become more evident over the past decade, especially related to chronic conditions such as diabetes. The level of methodological rigour across this body of work however is varied and outputs do not appear to have been developed or translated into clinical practice. The aim of this systematic review was to assess the latest guidelines, standards of care and current recommendations relative to people with chronic conditions to ascertain the level of supporting evidence concerning the management of foot health.

METHODS

A systematic search of electronic databases (Medline, Embase, Cinahl, Web of Science, SCOPUS and The Cochrane Library) for literature on recommendations for foot health management for people with chronic conditions was performed between 2000 and 2016 using predefined criteria. Data from the included publications was synthesised via template analysis, employing a thematic organisation and structure. The methodological quality of all included publications was appraised using the Appraisal for Research and Evaluation (AGREE II) instrument. A more in-depth analysis was carried out that specifically considered the levels of evidence that underpinned the strength of their recommendations concerning management of foot health.

RESULTS

The data collected revealed 166 publications in which the majority (102) were guidelines, standards of care or recommendations related to the treatment and management of diabetes. We noted a trend towards a systematic year on year increase in guidelines standards of care or recommendations related to the treatment and management of long term conditions other than diabetes over the past decade. The most common recommendation is for preventive care or assessments (e.g. vascular tests), followed by clinical interventions such as foot orthoses, foot ulcer care and foot health education. Methodological quality was spread across the range of AGREE II scores with 62 publications falling into the category of high quality (scores 6-7). The number of publications providing a recommendation in the context of a narrative but without an indication of the strength or quality of the underlying evidence was high (79 out of 166).

CONCLUSIONS

It is clear that evidence needs to be accelerated and in place to support the future of the Podiatry workforce. Whilst high level evidence for podiatry is currently low in quantity, the methodological quality is growing. Where levels of evidence have been given in in high quality guidelines, standards of care or recommendations, they also tend to be strong-moderate quality such that further strategically prioritised research, if performed, is likely to have an important impact in the field.

Reconsultation, self-reported health status and costs following treatment at a musculoskeletal Clinical Assessment and Treatment Service (CATS): a 12-month prospective cohort study

OBJECTIVES

To determine (1) reconsultation frequency, (2) change in self-reported health status, (3) baseline factors associated with reconsultation and change in health status and (4) associated healthcare costs and quality-adjusted life-years (QALYs), following assessment at a musculoskeletal Clinical and Assessment Treatment Service (CATS).

DESIGN

Prospective cohort study.

SETTING

Single musculoskeletal CATS at the primary-secondary care interface.

PARTICIPANTS

2166 CATS attenders followed-up by postal questionnaires at 6 and 12 months and review of medical records.

OUTCOME MEASURES

Primary outcome was consultation in primary care with the same musculoskeletal problem within 12 months. Secondary outcome measures were consultation at the CATS with the same musculoskeletal problem within 12 months, physical function and pain (Short Form-36), anxiety and depression (Hospital Anxiety and Depression Scale), time off work, healthcare costs and QALYs.

RESULTS

Over 12 months, 507 (38%) reconsulted for the same problem in primary care and 345 (26%) at the CATS. Primary care reconsultation in the first 3 months was associated with baseline pain interference (relative risk ratio 5.33; 95% CI 3.23 to 8.80) and spinal pain (1.75; 1.09 to 2.82), and after 3-6 months with baseline assessment by a hospital specialist (2.06; 1.13 to 3.75). Small mean improvements were seen in physical function (1.88; 95% CI 1.44 to 2.32) and body pain (3.86; 3.38 to 4.34) at 6 months. Poor physical function at 6 months was associated with obesity, chronic pain and poor baseline physical function. Mean (SD) 6-month cost and QALYs per patient were £422.40 (660.11) and 0.257 (0.144), respectively.

CONCLUSIONS

While most patients are appropriate for a 'one-stop shop' model, those with troublesome, disabling pain and spinal pain commonly reconsult and have ongoing problems. Services should be configured to identify and address such clinical complexity.

Impact of concurrent foot pain on health and functional status in people with knee osteoarthritis: data from the osteoarthritis initiative

OBJECTIVE

To document the prevalence of foot pain and foot pain laterality in people with knee osteoarthritis (OA) and to examine its impact on health and function.

METHODS

Participants from the Progression subcohort (n = 1,255, ages 45-79 years) of the Osteoarthritis Initiative with symptomatic tibiofemoral knee OA were included. Prevalence of foot pain, defined as pain in the foot/ankle, and foot pain laterality were determined. Health status was evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index, the Short Form-12 Health Survey, and the Center for Epidemiological Studies Depression Scale. Function was assessed using the 20-meter walk test (WT) and a repeated chair stand test. Differences in health and functional measures were compared between groups with and without foot pain using multivariate analysis of covariance.

RESULTS

One-fourth (n = 317 [25%]) of people with knee OA experienced concurrent foot pain, with the majority (n = 174 [55%]) reporting pain in both feet. After adjusting for covariates, people with foot pain scored worse on all health measures and on the 20-meter WT, compared to those without (P < 0.05). Differences in health and function were found between the bilateral and ipsilateral foot pain groups compared to those without foot pain (P < 0.05), but no differences were found with the contralateral group.

CONCLUSION

Foot pain is common in people with knee OA, and bilateral and ipsilateral foot pain adversely affect health and function, suggesting laterality is important. Further research is needed to establish the mechanism and interaction of pathology at these sites and to evaluate foot pain treatment in this population.

Foot problems in people with gout in primary care: baseline findings from a prospective cohort study

Background

Foot problems are common in people with gout yet the prevalence of current foot problems in people with gout and the burden they present to healthcare systems is not known. This cross-sectional study aimed to determine the prevalence and associations of hallux valgus, foot pain and disability in people with gout, and to assess the frequency with which foot problems lead to consultation with healthcare professionals.

Methods

Adults registered with 20 general practices who had consulted their GP about gout or been prescribed allopurinol or colchicine in the preceding two years were mailed a questionnaire. Prevalence of hallux valgus, foot pain in the last month, and disabling foot pain in the mailed population were ascertained using validated instruments and estimated by inverse-weighted logistic regression. Associations with socio-demographic, comorbid and gout-specific factors were examined using logistic regression. Participants were asked if they had seen health care professionals for foot problems within the preceding 12 months.

Results

One thousand one hundred eighty-four questionnaires were received (response 66 %). Prevalence of hallux valgus was 36.3 %, foot pain in the last month 22.3 % and disabling foot pain 14.5 %. Hallux valgus associated with age (adjusted OR 1.47 per 10-year increase, 95 % CI 1.26, 1.72) and female gender (2.03; 1.31, 3.15). Foot pain in the last month associated with age (1.24; 1.00, 1.55), obesity (BMI 30.0–34.9 2.67; 1.32, 5.38; BMI ≥ 35.0 3.16; 1.44, 6.93), mild depression (2.04; 1.09, 3.81) and polyarticular gout attacks (1.86; 1.18, 2.95). Disabling foot pain associated with age (1.42; 1.08, 1.87), obesity (BMI 30.0–34.9 3.73; 1.54, 9.09; BMI ≥ 35.0 4.36; 1.64, 11.64), depression (mild 2.63; 1.25, 5.53; moderate 3.53; 1.11, 11.26) and ischaemic heart disease (2.45; 1.32, 4.53). In the previous 12 months, 495 (42.8 %) reported consulting their GP about their feet and 281 (23.7 %) a podiatrist/chiropodist.

Conclusions

Foot problems are common in people with gout and frequently lead to healthcare consultation. Hallux valgus has similar associations to those seen in the general population, whereas foot pain associates with obesity and gout characteristics, and disabling foot pain with obesity and comorbidity. Patient assessment should consider foot problems and offer specific treatment where relevant.

The epidemiology of symptomatic midfoot osteoarthritis in community-dwelling older adults: cross-sectional findings from the Clinical Assessment Study of the Foot

Introduction

The foot is largely overlooked in calls for better characterisation of clinical phenotypes in osteoarthritis (OA). Yet the midfoot complex in particular has the potential to provide important insights into OA pathogenesis given its central role in lower limb load transmission and alignment. Its recent inclusion in radiographic atlases has paved the way for international studies. In this UK study, we provide the first comprehensive account of the descriptive epidemiology of symptomatic midfoot OA.

Methods

Participants aged ≥50 years registered with four general practices were recruited via a mailed health survey (n = 5109 responders) and research clinic (n = 560 responders). Symptomatic midfoot OA was defined as midfoot pain in the last 4 weeks, combined with radiographic OA in one or more joints (1st and 2nd cuneometatarsal, navicular first cuneiform and talonavicular joints) graded from weight-bearing dorso-plantar and lateral radiographs using a validated atlas. Prevalence estimates, overall and stratified by age, gender, and socio-economic class, were derived using multiple imputation and weighted logistic regression. Associations between symptomatic midfoot OA and current body mass index, previous injury, history of high-heeled footwear, nodal interphalangeal joint OA and patterns of comorbidity were estimated using binary logistic regression. Healthcare use was summarised.

Results

Symptomatic midfoot OA was present in 12.0 % (95 % CI: 10.9, 13.2) of the population aged over 50 years. Higher occurrence was observed in females, adults aged over 75 years, and those in intermediate/routine occupational classes. Obesity, previous foot/ankle injury, and pain in other weight-loaded joints, but not high-heeled footwear or nodal interphalangeal joint OA, were associated with increased risk of symptomatic midfoot OA. Persons with symptomatic midfoot OA were also more likely to report multiple non-musculoskeletal comorbidities, including diabetes. In the previous 12 months, the proportions consulting a general practitioner, physiotherapist or podiatrist/chiropodist about foot pain were 46.2 %, 18.5 % and 47.9 % respectively. A total of 64.7 % had used oral analgesia in the past month for foot pain (36.1 % paracetamol, 31.9 % mild/moderate opioids, 27.7 % NSAIDs).

Conclusions

Our study confirms that symptomatic OA frequently affects the midfoot. The patterns of associations are interpreted as being largely consistent with the role of mechanical factors in its pathogenesis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0693-3) contains supplementary material, which is available to authorized users.

The population prevalence of symptomatic radiographic foot osteoarthritis in community-dwelling older adults: cross-sectional findings from the clinical assessment study of the foot

OBJECTIVES

To estimate the population prevalence of symptomatic radiographic osteoarthritis (OA) affecting the 1st metatarsophalangeal joint (MTPJ), 1st and 2nd cuneometatarsal joints (CMJs), navicular first cuneiform joint (NCJ) and talonavicular joint (TNJ) in community-dwelling older adults.

METHODS

9334 adults aged ≥50 years registered with four general practices were mailed a health survey. Responders reporting foot pain within the last 12 months were invited to undergo weight-bearing dorso-plantar and lateral radiographs of both feet. OA at the 1st MTPJ, 1st and 2nd CMJs, NCJ and TNJ was graded using a validated atlas. Population prevalence estimates for symptomatic radiographic foot OA overall and for each joint were calculated using multiple imputation and weighted logistic regression modelling to account for missing data and non-response.

RESULTS

5109 health surveys were received (adjusted response 56%). Radiographs were obtained on 557 participants. Overall population prevalence of symptomatic radiographic OA was 16.7% (95% CI 15.3% to 18.0%), 1st MTPJ 7.8% (6.7% to 8.9%), 1st CMJ 3.9% (2.9% to 4.9%), 2nd CMJ 6.8% (5.7% to 7.8%), NCJ 5.2% (4.0% to 6.4%) and TNJ 5.8% (4.8% to 6.9%). With the exception of the 1st CMJ, prevalence was greater in females than males, increased with age and was higher in lower socioeconomic classes. Three-quarters of those with symptomatic radiographic OA reported disabling foot symptoms.

CONCLUSIONS

While cautious interpretation due to non-response is warranted, our study suggests that symptomatic radiographic foot OA affects one in six older adults and the majority report associated disability. Clinicians should consider OA as a possible cause of chronic foot pain in older people.

Prevalence of knee pain and knee OA in southern Sweden and the proportion that seeks medical care

OBJECTIVE

The aim of this study was to estimate the prevalence of frequent knee pain in radiographic, symptomatic and clinically defined knee OA in middle-aged and elderly patients and the proportion that seeks medical care.

METHODS

In 2007 a random sample of 10 000 56- to 84-year-old residents of Malmö, Sweden, were questioned about knee pain. We classified subjects reporting knee pain with a duration of at least 4 weeks as having frequent knee pain. A random sample of 1300 individuals with frequent knee pain and 650 without were invited for assessment by the ACR clinical knee OA criteria and for bilateral weight-bearing knee radiography. We considered a Kellgren-Lawrence grade ≥2 as radiographic knee OA and that in combination with frequent knee pain as symptomatic knee OA. By linkage with the Skåne Healthcare Register, we determined the proportion of subjects that had consulted for knee OA or pain.

RESULTS

The 10 000 subjects had a mean age of 70 years (s.d. 7.6), a mean BMI of 27.1 kg/m(2) and 62% were women. The prevalence of frequent knee pain was 25.1% (95% CI 24.1, 26.1), higher in women and similar across age groups. The prevalence of radiographic knee OA was 25.4% while 15.4% had either symptomatic or clinically defined knee OA. Of these, 68.9% consulted a physician for knee OA or pain during 2004-11.

CONCLUSION

Fifteen per cent of middle-aged or elderly individuals have knee OA and symptoms. About one in three of those do not consult a physician. Inefficient care of OA and self-coping may be an explanation.

Midfoot and forefoot osteoarthritis

BACKGROUND

Foot osteoarthritis (OA) is linked with chronic foot pain and functional impairment.

OBJECTIVE

To review the current knowledge on midfoot and forefoot OA.

METHODS

PubMed, CINAHL, PEDro, and the ISI Web of Science databases (1950-2013) were searched for keywords: foot OA, midfoot OA, forefoot OA and metatarsal OA. The search was limited to reports in human subjects and English language. Published cohort, cross-sectional studies and clinical trials relating to epidemiology, clinical features, functional impairment, risk factors and treatment were included.

RESULTS

We found heterogeneity in the design, radiographic views and grading systems used among studies. Most of the literature focused on radiographic OA, being the prevalence between 0.1% and 61%, depending on gender, age and joint evaluated. The age and female gender were the main associated factors, whereas structural (bone length) and mechanical factors (hypermobility, altered tarso-metatarsal stress, etc.) seemed to be related. Various treatments are widely used, i.e. physical therapy, orthotics, steroid injection, analgesics and arthrodesis. However, scarce research supports their efficacy.

CONCLUSION

Most of the current knowledge comes from observational and small case-control studies. Future population-based studies as well as controlled studies are essential to understand the risk factors and to evaluate the effectiveness of treatment options.

Evaluation of the measurement properties of the Manchester foot pain and disability index

Background

The Manchester Foot Pain and Disability Index (MFPDI, 19 items) was developed to measure functional limitations, pain and appearance for patients with foot pain and is frequently used in both observational studies and randomised controlled trials. A Dutch version of the MFPDI was developed. The aims of this study were to evaluate all the measurement properties for the Dutch version of the MFPDI and to evaluate comparability to the original version.

Method

The MFPDI was translated into Dutch using a forward/backward translation process. The dimensionality was evaluated using exploratory and confirmatory factor analysis. Measurement properties were evaluated per subscale according to the COSMIN taxonomy consisting of: reliability (internal consistency, test-retest reliability and measurement error), validity (structural validity, content validity and cross-cultural validity comparing the Dutch version to the English version) responsiveness and interpretation.

Results

The questionnaire consists of three scales, measuring foot function, foot pain and perception. The reliability of the foot function scale is acceptable (Cronbach’s α > 0.7, ICC = 0.7, SEM = 2.2 on 0-18 scale). The construct validity of the function and pain scale was confirmed and only the pain scale contains one item with differential item functioning (DIF). The responsiveness of the function and pain scale is moderate when compared to anchor questions.

Conclusion

Results using the Dutch MFPDI version can be compared to results using the original version. The foot function sub-scale (items 1-9) is a reliable and valid sub-scale. This study indicates that the use of the MFPDI as a longitudinal instrument might be problematic for measuring change in musculoskeletal foot pain due to moderate responsiveness.

"Somebody to say 'come on we can sort this'": a qualitative study of primary care consultation among older adults with symptomatic foot osteoarthritis

Objective

To examine the experiences of primary care consultation among older adults with symptomatic foot osteoarthritis (OA).

Methods

Eleven participants (6 women and 5 men) ages 56–80 years who had radiographically confirmed symptomatic foot OA and consulted a general practitioner in the last 12 months for foot pain were purposively sampled. Semistructured interviews explored the nature of the foot problem, help-seeking behaviors, and consultation experiences. Verbatim transcripts were analyzed using interpretative phenomenological analysis.

Results

The decision to consult a physician was often the outcome of a complex process influenced by quantitative and qualitative changes in symptoms, difficulty maintaining day-to-day roles and responsibilities and the effect this had on family and work colleagues, and a reluctance to present a fragile or aging self to the outside world. Self-management was commonly negotiated alongside multimorbidities. Upon seeking help, participants often believed they received limited information, they were given a brief or even cursory assessment, and that treatment was focused on the prescription of analgesic drugs.

Conclusion

This is the first qualitative study of primary care experiences among patients with symptomatic foot OA. The experience of primary care seldom appeared to move beyond a label of arthritis and an unwelcome emphasis on pharmacologic treatment.

Effects of lower body positive pressure on cardiovascular responses during walking in elderly women

This study was undertaken to investigate the effects of lower body positive pressure (LBPP) on cardiovascular responses during a 15-min walking trial in young (22.1+/-0.4 years) and elderly women (67.8+/-1.1 years). The application of 20 mm Hg LBPP reduced ground reaction forces by 31.2+/-0.5 kgw in both groups. We hypothesized that cardiovascular responses to LBPP during walking were different between the young and elderly subjects. Applying 20 mm Hg of LBPP increased diastolic and mean blood pressure but not systolic blood pressure in both groups. LBPP-induced reduction in heart rate (HR) occurred more quickly in the young group compared to the elderly group (p<0.05). Applying LBPP also decreased double product (systolic blood pressure x HR) in both groups, suggesting that LBPP reduces myocardial oxygen consumption during exercise. These results suggest that heart rate responses to LBPP during exercise vary with increasing age.

The clinical assessment study of the foot (CASF): study protocol for a prospective observational study of foot pain and foot osteoarthritis in the general population

BACKGROUND

Symptomatic osteoarthritis (OA) affects approximately 10% of adults aged over 60 years. The foot joint complex is commonly affected by OA, yet there is relatively little research into OA of the foot, compared with other frequently affected sites such as the knee and hand. Existing epidemiological studies of foot OA have focussed predominantly on the first metatarsophalangeal joint at the expense of other joints. This three-year prospective population-based observational cohort study will describe the prevalence of symptomatic radiographic foot OA, relate its occurrence to symptoms, examination findings and life-style-factors, describe the natural history of foot OA, and examine how it presents to, and is diagnosed and managed in primary care.

METHODS

All adults aged 50 years and over registered with four general practices in North Staffordshire, UK, will be invited to participate in a postal Health Survey questionnaire. Respondents to the questionnaire who indicate that they have experienced foot pain in the preceding twelve months will be invited to attend a research clinic for a detailed clinical assessment. This assessment will consist of: clinical interview; physical examination; digital photography of both feet and ankles; plain x-rays of both feet, ankles and hands; ultrasound examination of the plantar fascia; anthropometric measurement; and a further self-complete questionnaire. Follow-up will be undertaken in consenting participants by postal questionnaire at 18 months (clinic attenders only) and three years (clinic attenders and survey participants), and also by review of medical records.

DISCUSSION

This three-year prospective epidemiological study will combine survey data, comprehensive clinical, x-ray and ultrasound assessment, and review of primary care records to identify radiographic phenotypes of foot OA in a population of community-dwelling older adults, and describe their impact on symptoms, function and clinical examination findings, and their presentation, diagnosis and management in primary care.