Vascular assessment techniques of podiatrists in Australia and New Zealand: a web-based survey

What are the current diabetic foot assessment methods in private podiatry practices in Flanders, Belgium: an exploratory mixed method study

BACKGROUND

Diabetic foot assessments detect patients at risk for developing a diabetes-related foot ulceration and can significantly reduce the risk of amputation. In order to organize this assessment effectively, diabetic foot assessment guidelines are required according to the International Working Group of the Diabetic Foot. However, these international guidelines have not been adapted into a national guideline for podiatrists in Flanders, Belgium. This study aims to identify the methods and guidelines currently used to assess the diabetic foot in private podiatry practices in Flanders, Belgium and to explore the podiatrists' opinions on developing a national diabetic foot assessment guideline.

METHODS

This exploratory mixed method study was composed of an anonymous online survey comprising of open- and closed-ended questions followed by 1:1 online semi-structured interviews. Participants were recruited via e-mail and a closed private Facebook group of podiatry alumni. Data was analyzed using SPSS statistics and thematic analysis described by Braun and Clarke.

RESULTS

This study showed that the vascular assessment of the diabetic foot exists solely of a medical history and palpation of the pedal pulses. Non-invasive tests such as doppler, toe brachial pressure index or ankle brachial pressure index are seldom used. Only 66% reported to use a guideline for the diabetic foot assessment. There was a variety of reported guidelines and risk stratification systems in use in private podiatry practices in Flanders, Belgium.

CONCLUSION

Non-invasive tests such as the doppler, ankle brachial pressure index or toe brachial pressure index are rarely used for the vascular assessment of the diabetic foot. Diabetic foot assessment guidelines and risk stratification systems to identify patients at risk for developing a diabetic foot ulcer were not frequently used. International guidelines of the International Working Group of the Diabetic Foot have not yet been implemented in private podiatry practices in Flanders, Belgium. This exploratory research has provided useful information for future research studies.

Commentary: Demystifying Doppler – revisiting a vital diagnostic tool

Doppler is the most commonly utilised vascular assessment tool by podiatrists in Australia and the United Kingdom. Doppler is a key component of many international guidelines for vascular assessment. Used alongside pressure measurements such as ankle and toe-brachial indices, Doppler assists podiatrists to diagnose, triage and subsequently manage patients with peripheral arterial disease. This commentary aims to clarify the importance, technique, and interpretation of continuous wave handheld Doppler in podiatry practice. This commentary presents discussion on the equipment and optimal test conditions for use of Doppler, and guidance on the technique required in podiatry clinical practice. Furthermore, there is a focus on interpretation of the output from Doppler including both audio and visual output. There is in depth discussion about identifying pathology and integration into the clinical management plan.

The ankle brachial index in people with and without diabetes: intra-tester reliability

Background

The ankle-brachial index (ABI) is widely used for determining the presence and severity of peripheral arterial disease (PAD), and current guidelines suggest it should be used to monitor possible progression in affected individuals. It is therefore important that the technique demonstrates adequate reliability for repeated measurements. Existing studies suggest that the ABI is reliable in the general population however, there is a lack of evidence for the reliability of the ABI in people with diabetes. The aim of this study was to investigate the intra-tester reliability of the ABI in people with and without diabetes.

Methods

Eighty-five participants (40 with and 45 without diabetes) underwent ankle and brachial systolic blood pressure measurements by a single clinician during two testing sessions. Intraclass correlation coefficients (ICC), their 95% limits of agreement, standard error of measurement and minimal detectable change were determined.

Results

Intra-tester reliability of the ABI was found to be good (ICC: 0.80), however sub-group analysis of participants with and without diabetes found that ABI was slightly less reliable in people with diabetes (ICC: 0.78) than in those without (ICC: 0.82). The relatively large limits of agreement (− 0.16 to 0.16), standard error of measurement (0.03 overall, 0.04 for the diabetes group), and minimal detectable change (0.08 overall, 0.11 for the diabetes group) suggest that a large change in ABI is required for it to demonstrate a true change rather than the result of measurement variability. The minimal detectable change for the ABI was 0.08 overall, and 0.11 for the diabetes group.

Conclusions

The ABI demonstrated good reliability in all groups analysed. However, the wide limits of agreement and considerable standard error of measurement obtained support the use of multiple methods of vascular assessment for ongoing monitoring of lower limb vascular status.

Accurate Noninvasive Arterial Assessment of the Wounded Lower Limb: A Clinical Challenge for Wound Practitioners

Arterial investigations are an essential part of lower extremity wound assessment. The results of these investigations assist the wound clinician to determine the etiology of the wound, predict healing capacity, and inform further management. There are a number of noninvasive testing methods available to practitioners, all with varying levels of reliability and accuracy. Clinical wound assessment guidelines give varied recommendations when it comes to lower limb vascular assessment in the presence of a wound. This leaves clinicians with little guidance on how to choose the most appropriate test, and uncertainty remains about which tests provide the most accurate information in different patient-specific contexts. Conditions such as advanced age, diabetes, and renal disease are known to affect the accuracy of some commonly used lower limb arterial assessment methods, and alternate testing methods should be considered in these cases. This seminal review discusses the reliability and accuracy of lower limb vascular assessment methods used to guide lower limb arterial assessment in the presence of wounds.

Survey research in podiatric medicine: An analysis of the reporting of response rates and non-response bias

BACKGROUND

Survey research is common practice in podiatry literature and many other health-related fields. An important component of the reporting of survey results is the provision of sufficient information to permit readers to understand the validity and representativeness of the results presented. However, the quality of survey reporting measures in the body of podiatry literature has not been systematically reviewed.

OBJECTIVE

To examine the reporting of response rates and nonresponse bias within survey research articles published in the podiatric literature in order to provide a foundation with regard to the development of appropriate research reporting standards within the profession.

METHODS

This study reports on a secondary analysis of survey research published in the Journal of the American Podiatric Medical Association, the Foot, and the Journal of Foot and Ankle Research. 98 surveys published from 2000 to 2018 were reviewed and data abstracted regarding the report of response rates and non-response bias.

RESULTS

67 surveys (68.4%) report a response rate while only 36 articles (36.7%) mention non-response bias in any capacity.

CONCLUSIONS

The findings suggest that there is room for improvement in the quality of reporting response rates and nonresponse in the body of podiatric literature involving survey research. Both nonresponse and response rate should be reported to assess survey quality. This is particularly problematic for studies that contribute to best practices.

Lower limb vascular assessment techniques of podiatrists in the United Kingdom: a national survey

BACKGROUND

Podiatric vascular assessment practices in the United Kingdom (UK) are currently unknown. This study aimed to describe the current practices for performing lower limb vascular assessments by podiatrists in the UK, and, to investigate the effect of practitioner characteristics, including education level and practice setting, on the choice of tests used for these assessments.

METHODS

A cross-sectional observational online survey of registered podiatrists in the UK was conducted using SurveyMonkey® between 1st of July and 5th of October 2018. Item content related to: practitioner characteristics, vascular testing methods, barriers to completing vascular assessment, interpretation of vascular assessment techniques, education provision and ongoing management and referral pathways. Descriptive statistics were performed, and multinomial logistic regression analyses were used to determine whether practitioner characteristics could predict the choice of vascular tests used.

RESULTS

Five hundred and eighty five participants accessed the online survey. After drop-outs and exclusions, 307 participants were included in the analyses. Comprehensive vascular assessments had most commonly been performed once (15.8%) or twice (10.4%) in the past week. The most common indicators for performing vascular assessment were symptoms of suspected claudication (89.3%), suspected rest pain (86.0%) and history of diabetes (85.3%). The most common barrier to performing vascular assessment was time constraints (52.4%). Doppler examination (72.3%) was the most frequently reported assessment type, with ankle-brachial index (31.9%) and toe brachial index (5.9%) less frequently performed. There were variable interpretations of vascular test results. The most common topic for education was smoking cessation (69.5%). Most participants (72.2%) were confident in determining ongoing management, with the majority referring to the patient's general practitioner (67.6%). Practitioner characteristics did not predict the types of vascular tests performed.

CONCLUSION

The majority of vascular assessments currently performed by podiatrists in the UK are inconsistent with UK or international vascular guidelines and recommendations. Despite this, most podiatrists felt confident in diagnosing, referring and managing patients with peripheral arterial disease (PAD), however many felt they needed more education to feel confident to assist patients with PAD to manage their cardiovascular risk factors.

How does a short period of exercise effect toe pressures and toe-brachial indices? A cross-sectional exploratory study

BACKGROUND

Whilst post exercise ankle-brachial indices (ABI) are commonly used to help identify peripheral arterial disease (PAD), the role of post exercise toe pressures (TP) or toe-brachial indices (TBI) is unclear. The aim of this study was to determine, in a population without clinical signs of PAD, the effect that 30 s of weight-bearing heel raises has on TP and TBI values. Additionally, the ability of resting TP and TBI values to predict change in post-exercise values using the heel raise method was investigated.

METHODS

Participants over the age of 18 with a resting TBI of ≥0.60 and ABI between 0.90 and 1.40, without diabetes, history of cardiovascular disease and not currently smoking were included. Following ten minutes of supine rest, right TP and bilateral brachial pressures were performed in a randomized order using automated devices. Participants then performed 30 s of weight-bearing heel raises, immediately after which supine vascular measures were repeated. Data were assessed for normality using the Shapiro-Wilk test. For change in TP and TBI values the Wilcoxon Signed-Rank Test was performed. For correlations between resting and change in post exercise values, the Spearman Rank Order Correlations were performed, and where significant correlation identified, a linear regression undertaken.

RESULTS

Forty-eight participants were included. A statistically significant decrease was seen in the median TP from resting 103.00 mmHg (IQR: 89.00 to 124.75) to post exercise 98.50 mmHg (IQR: 82.00 to 119.50), z = - 2.03, p = 0.04. This difference of 4.50 mmHg represents a 4.37% change and is considered a small effect size (r = 0.21). The median TBI also demonstrated a statistically significant decrease from resting 0.79 (IQR: 0.68 to 0.94) to post exercise 0.72 (IQR: 0.60 to 0.87), z = - 2.86, p = < 0.01. This difference of 0.07 represents an 8.86% change and is considered a small effect size (r = 0.29). Linear regression demonstrated that resting TBI predicted 22.4% of the variance in post exercise TBI, p = < 0.01, coefficients beta - 0.49.

CONCLUSIONS

Thirty seconds of weight-bearing heel raises resulted in a similar decrease in TBI values seen in longer periods of exercise. TP values also showed a decrease post exercise; however this was contrary to previous studies.

Survey of ultrasound practice amongst podiatrists in the UK

Background

Ultrasound in podiatry practice encompasses musculoskeletal ultrasound imaging, vascular hand-held Doppler ultrasound and therapeutic ultrasound. Sonography practice is not regulated by the Health and Care Professions Council (HCPC), with no requirement to hold a formal qualification. The College of Podiatry does not currently define ultrasound training and competencies.

This study aimed to determine the current use of ultrasound, training received and mentorship received and/or provided by podiatrists using ultrasound.

Methods

A quantitative study utilising a cross-sectional, on-line, single-event survey was undertaken within the UK.

Results

Completed surveys were received from 284 podiatrists; 173 (70%) use ultrasound as part of their general practice, 139 (49%) for musculoskeletal problems, 131 (46%) for vascular assessment and 39 (14%) to support their surgical practice. Almost a quarter (n = 62) worked for more than one organisation; 202 (71%) were employed by the NHS and/or private sector (n = 118, 41%).

Nearly all (93%) respondents report using a hand-held vascular Doppler in their daily practice; 216 (82%) to support decisions regarding treatment options, 102 (39%) to provide diagnostic reports for other health professionals, and 34 (13%) to guide nerve blocks.

Ultrasound imaging was used by 104 (37%) respondents primarily to aid clinical decision making (n = 81) and guide interventions (steroid injections n = 67; nerve blocks n = 39). Ninety-three percent stated they use ultrasound imaging to treat their own patients, while others scan at the request of other podiatrists (n = 28) or health professionals (n = 18). Few use ultrasound imaging for research (n = 7) or education (n = 2).

Only 32 (11%) respondents (n = 20 private sector) use therapeutic ultrasound to treat patients presenting with musculoskeletal complaints, namely tendon pathologies.

Few respondents (18%) had completed formal post-graduate CASE (Consortium for the Accreditation of Sonographic Education) accredited ultrasound courses.

Forty (14%) respondents receive ultrasound mentorship; the majority from fellow podiatrists (n = 17) or medical colleagues (n = 15). Over half (n = 127) who do not have ultrasound mentorship indicated they would like a mentor predominantly for ultrasound imaging. Fifty-five (19%) report they currently provide ultrasound mentorship for others.

Conclusions

Understanding the scope of ultrasound practice, the training undertaken and the requirements for mentorship will underpin the development of competencies and recommendations defined by the College of Podiatry to support professional development and ensure safe practice.

Electronic supplementary material

The online version of this article (10.1186/s13047-018-0263-4) contains supplementary material, which is available to authorized users.

A targeted screening method for non-invasive vascular assessment of the lower limb

BACKGROUND

Podiatrists routinely perform non-invasive lower limb vascular assessment, however frequently cite time as a major barrier in performing regular assessment. The aim of this study was to develop an evidence-based vascular assessment method to guide podiatrists' decision-making processes to aid in timely vascular assessment in at risk populations.

METHOD

The sample underwent brachial pressure measurement, ankle pressures, toe pressure and Doppler waveform with colour duplex ultrasound (CFDU) used as the reference standard. Both the targeted screening method and the American Heart Association (AHA) guideline for vascular screening were then applied to the data set and sensitivity and specificity of each method was calculated.

RESULTS

One hundred nineteen participants were included. Sensitivity of the targeted screening method (62%, 95% CI 47.17-75.35) was higher than the AHA method (49%, 95% CI 34.75-63.40), however, specificity of the AHA method (94%, 95% CI 85.62-98.37) was higher than the targeted screening method (85%, 95% CI 74.26-92.60). Diagnostic accuracy was similar with the AHA method yielding 74% diagnostic accuracy and the targeted screening method 73%.

CONCLUSION

The targeted screening method and the broad international guideline demonstrated similar accuracy, however clinicians may save time using the targeted screening method. This study highlights the difficulties in obtaining accuracy in lower limb vascular assessment in general.