Abstracts from the Royal College of Podiatry Annual Conference

Background: The COVID-19 pandemic and lockdown restrictions drastically modified the delivery of clinical care in musculoskeletal (MSK) settings. Providers rapidly replaced traditional face-to-face consultation (F2FC) with video consultations (VC), requiring patients to quickly adapt to this new modality. There is uncertainty regarding how patients responded to VCs and the influence upon their assessment. This study aimed to identify and evaluate participant satisfaction levels and preference for modality following both a VC and F2FC.

Methods: A cross-sectional questionnaire study was conducted for patients who had experienced both modalities under a private London-based MSK clinic. A 35-item questionnaire was developed specifically for the purpose of this study. Quantitative and qualitative items were used to ensure a wide range of feedback was achieved. Following a pilot study, the online questionnaire was launched and distributed to participants via email.

Results: 177 of 500 (35.4%) invited participants completed the questionnaire. Results identified a statistically significant higher level of participant satisfaction with F2FC. It was perceived as superior to VC in the majority of clinical applications and the preference for future appointments by 86.4% of participants.

Conclusions: Traditional physical interactions and communication were the leading factors of satisfaction and preference for F2FC, which were perceived as limitations with VC. Participants identified VC as a valuable tool and recommended it to be used in conjunction with F2FC. Participants reported higher satisfaction levels and a stronger preference for F2FC for their MSK complaint, but still supported the implementation of VC as a future option.

Background: The aim of the study was to assess if adding information on clinical, systemic and social environmental factors to the Scottish Foot Ulcer Risk Score (SFURS) improves risk stratification for diabetic foot ulceration.

Method: We extracted and analysed the anonymised digital health data from 59,582 people with diabetes from the Scottish Care Information – Diabetes Collaboration (SCI-diabetes) register. We extracted data on their earliest SFURS score and supplemented this with information on age, gender, time since diabetes diagnosis, Charlson comorbidity index, Scottish Index of Multiple deprivation, ethnicity and type of diabetes. We recorded incident diabetic foot ulcer event between 2007-2016. Using survival analysis methods, we compared the discriminative performance of the following two predictive models using Harrel’s C-statistic: (MODEL-1) existing SFURS score; and (MODEL-2) SFURS plus all the aforementioned prognostic factors.

Background: Multiple Sclerosis (MS) is a complex disease which affects the central nervous system. The myelin sheath that protects the nerve fibres of the body is damaged by its own immune system (demyelination). Under NICE guidelines CG186, podiatrists are not currently included within the Multiple Sclerosis rehabilitation team, with access to podiatric treatment in secondary care available for those with a specific need.

Methods: A scoping review of the effects of MS on the lower limb (using PRISMA-ScR) was undertaken to examine the extent, range and nature of any research activity that has already been completed in this area of podiatric medicine, subsequently identifying research gaps in existing literature. A PPI advisory panel was established, comprising of ten members, aimed at highlighting the effects of MS on lower limb health. The PPI advisory panel was formed through social media recruitment, utilising Twitter as the primary platform.

Results: The COM-B model has been used as a framework for analysis, along with keywords used as discussion strategy. The Guidance for Reporting Involvement of Patients and Public 2 - GRIPP2 is the checklist that has been utilised to report the themes and initial findings of the PPI meetings. This guidance resembles the logic model, highlighting that evaluating participation is a complex activity, which provides the fundamental key to ensuring that public involvement and participation activities and programmes generate learning and results, and, improve future participation practices.

Conclusions: The initial findings have identified that there is scope for further research of the utilisation of podiatrists in the management and rehabilitation of lower limb health in patients with MS. The dialogue of the panel is encouraging with a host of examples provided as evidence that podiatric interventions could facilitate meaningful change to the rehabilitation service and have a great impact on both patients and carers.

Background: Depression and diabetes have ranked amongst the defining epidemics of the 21st century, given the current explosion in the prevalence rates of both these conditions, therefore it is not surprising that these two conditions could interact when both are present, leading to additional morbidity and a higher mortality risk in patients living with diabetes. Despite this, the specific relationship between depression and DPN remains unclear. This study aimed to determine any relationship between having diabetic peripheral neuropathy and the development of depressive symptoms in patient with type 2 diabetes mellitus (T2DM).

Methods: A comparative non-experimental study was conducted. Ninety five T2DM individuals aged 65 years and more were recruited. The sample was divided into two groups; 50 participants with T2DM only and 45 participants with DPN. The Patient Health Questionnaire-9 (PHQ-9) was used to collect information about low mood/depression symptoms in the recruited subjects.

Results: Participants with DPN recorded higher scores of PHQ-9 than those with T2DM only. The mean PHQ 9 score for the Diabetic Peripheral Neuropathy group (6.09) was significantly higher than the mean PHQ 9 score for the T2DM group (2.24) (p<0.001). Participants with DPN were more likely to have a mild/moderate or moderately severe low mood/depression symptoms, when compared to Type 2 DM participants who exhibited minimal to no low mood/depressive symptoms.

Conclusions: The association between diabetic neuropathy and depression is confirmed, with significant depressive symptoms found in patients with neuropathy when compared to patients with diabetes with no complications. Therefore, complaints caused by DPN and emotional problems associated with DPN should be addressed in the management of DPN in order to prevent depressive symptoms. A call for change in screening practices to help identify patients with DM and depressive symptoms is warranted.

Background: Children with symptomatic pes planus frequently present for care but there remains uncertainty about how best to manage them. Currently, management varies considerably within and between professions. Corrective surgery remains rare but exercise, foot orthoses, and advice regarding suitable footwear are commonly provided in line with the international consensus. We intend to test frequently used interventions (exercise and advice, exercise and advice plus prefabricated insoles, and exercise and advice plus custom made insoles) in a subsequent RCT. Each of these interventions are multifaceted and considered complex so require developing prior to starting the trial.

Methods: We used a modified Nominal Group Technique combining an electronic survey with two face-to-face meetings to achieve consensus on the final logic model and menu of options for each intervention.

Results: In total 16 healthcare professionals took part in the consensus meetings (seven at Eastbourne, and nine in Salford). These consisted of 11 podiatrists, two orthotists, two physiotherapists, and one orthopaedic surgeon.

Conclusions: Our novel modification of the nominal group technique produced a coherent logic model and shortlist of options for each of the interventions that explicitly enable adaptability. We formed consensus on the range of what is permissible within each intervention so that their integrity is kept intact, and they can be adapted and pragmatically applied. The process of combining survey data with face-to-face meetings has ensured the interventions mirror contemporary practice and may provide a template for other trials.

Background: Quantifying plantar pressure throughout periods of development enables us to gain an understanding of typical changes in foot function occurring alongside motor development. The aim of this review was to synthesise existing study outcomes, which report plantar pressure patterns of infants and children, to explore changes in foot function occurring throughout childhood.

Methods: A narrative approach was adopted, and a literature search undertaken using three research platforms: Science Direct, PubMed, Google Scholar. From the search, 263 articles were found. Articles were included if written in English, included experimental plantar pressure pattern data, and recorded data with electronic pressure measurement systems, from typically developing feet of infants and children up to 13 years of age. Fifteen articles met the inclusion criteria and were included in the review.

Results: By scoping the literature, plantar pressure values (e.g. contact area, maximum force) were found to increase in most foot regions with age but decrease at the midfoot during infancy and childhood. Thus, plantar pressure patterns evolve as infants and children become more proficient in walking, highlighting a trajectory of foot development in infants and children. Several limitations of existing studies were also identified including the use of cross-sectional designs and inconsistencies in data collection protocols and data analysis. No reports were identified of earliest stages of foot function evolution.

Conclusions: Further work could describe how the foot develops and experiences load prior to walking and as independent walking evolves, providing the scientific community with baseline knowledge of foot development.

Background: Robust knowledge of foot development during infancy is lacking and coupled with recent lessons from developmental psychology literature, alternative approaches to biomechanical evaluation of gait in infants are needed. Small Steps was a five-year funded research programme, (launched 2016) to investigate changes occurring in infant feet as they develop as weight-bearing structures. The purpose of this abstract is to share our reflection on data collection with infants.

Methods: A two-site longitudinal study was designed with four visits representing specific motor development milestones (reach for feet, pull-up to stand, onset of walking and confident walking). Across both sites, we designed modified gait labs (baby spaces) to capture real-world motion strategies, which have high external validity and represent typical bouts of infant walking. Our data collection space included a gated area, creche flooring and central pressure platform surrounded by motion capture cameras. Tasks were performed on the pressure platform at each visit and during the final two visits (once the infant was walking) kinematic data were also collected. Each visit also included measurement of anthropometrics and skin properties.

Results: 131 infants attend the first visit of the longitudinal study, within 21 days of reaching for their feet. 78 of these infants complete the fourth visit, within 21 days of being stable confident independent walkers. Participant loss was due to drop-out, exclusion and ceasing testing due to the COVID-19 pandemic.

Conclusions: The longitudinal study design was challenging in terms of recruitment and continued engagement with families. Booking visits close to milestone achievement was also difficult to schedule. Activities during data collection required effective explanation to parents and being sensitive to concerns alongside age-appropriate skills to keep infants engaged. Novel approaches to data analysis have been implemented such as floating lab coordinate systems for kinematics and personalised age-appropriate masks for pressure analysis.

Background: Haemarthrosis is an inherent clinical feature of haemophilia A and B [1]. Whilst annual joint bleed rates are commonly reported, there is a lack of information on bleed rates, joint health in individual joints and the impact of ankle haemarthropathy [2].

Methods: Ethical approval was obtained (IRAS: 206141, R&D:PD16/227) A nationwide prevalence study was undertaken in conjunction with the United Kingdom Haemophilia Centres Doctors Organisation, National Haemophilia Database. A further multicentre study to determine the impact of ankle haemarthropathy was undertaken across 18 haemophilia centres in England, Wales and Scotland.

Results: Prevalence: 2238 cases were identified; 273 reported ≥75% simultaneous Haemtrack compliance and Haemophilia Joint Health Scores (HJHS) data. Higher HJHS were reported for the ankle joint compared to the knee and elbow, confirming that the ankle joint is the most affected joint in people with haemophilia.

Conclusions: In adults the ankle is the most common site of haemarthrosis and is disproportionally affected by haemarthropathy. The associated impact is severe, and the new data provides a benchmark to potentially evaluate emerging pharmacological and targeted non-pharmacological treatments. Interventions such as foot orthoses and modified footwear have a role in delaying haemarthropathy and improving QoL.

Background: The Rheumatoid Arthritis Foot Disease Activity Index (RADAI-F5) is a valid PROM for measuring foot disease activity in rheumatoid arthritis (RA). This study aims to understand the clinical potential of the RADAI-F5 as a tool to inform management.

Methods: 60-minute, semi-structured, one-on-one Microsoft Teams interviews with adult RA patients and rheumatologists, physiotherapists, and podiatrists involved in treating RA patients was conducted as part of qualitative research. Interviews involved open-ended questions to explore barriers and facilitators to the clinical application of the RADAI-F5 and were audio-recorded and transcribed verbatim, with each participant verifying the transcript to establish rigour. Inductive thematic data analysis was applied using Nvivo11.

Results: Eight RA participants: 7 females; mean [standard deviation, SD] age 52.4 [9.5], mean [SD] disease duration 16.1 [16.4] and eight clinicians; mean [SD] age 46.75 [5.3], mean [SD] years of clinical experience of 19.5 [2.21] participated. Four main themes supporting the clinical utility of the RADAI-F5 were identified. These included; 'clinical feasibility' as the tool is short and quick to complete; 'promoting patient-clinician communication' as it can identify areas of concern that may be under-recognised by clinicians; 'monitoring status and treatments longitudinally' as implementing the RADAI-F5 could inform an individuals' management and; 'patient involvement,' since the tool may trigger patients to be more involved in their foot health self-management. Three themes were identified as potential barriers to implementation; 'practical difficulties, including lack of time during appointments; 'lack of validity', as clinicians were hesitant to use the RADAI-F5 until its validity is established further; and, 'lack of an electronic database', since there is currently no electronic system for reporting RADAI-F5 results.

Conclusions: The RADAI-F5 has significant potential as a clinical tool to aid foot disease management in RA. Nevertheless, some barriers to implementation need to be addressed to enable widespread use in rheumatology clinics.

Methods: The FEAT home visits ran from April 2020-November 2020. During this time we had a total case load of 34 patients.

Results: At the start 85% (N=29) had severe ulceration (SINBAD score 3-6), which reduced to 50% (N=17), an improvement of 35%. During this time 27% (N=9) healed, and 29% of patients (N=10) had an improved SINBAD score. There were 6 deaths (18%), none foot related, and one was due to Covid-19.Two admissions occurred (6%), one was for a BKA due to osteomyelitis of the fibula. The other admission was due to sepsis that was picked up on the patients first FEAT visit.

Conclusions: The FEAT visits were an effective way of providing a high level of holistic diabetes foot care in the patient’s home, helping to prevent hospital admissions and amputations, whilst also protecting them from the risk of covid-19 infection.

Background: The extensive impact COVID-19 has had on the provision of care in outpatient departments has been an especially concerning time for service users. This has been a particular worrying time for those living with active diabetic foot ulceration who rely on regular consultations with their foot protection team. The aim of this pilot study was to investigate the patients perception on the changes to the provision of care during the government imposed pandemic restrictions and establish the impact this had on the physical and psychosocial wellbeing of this patient cohort.

Method: Patients who had active diabetic foot disease prior to the first pandemic lockdown on the 16th of March 2020 or who developed a diabetic foot ulcer during the pandemic were invited to participate at their routine appointment. This study consisted of a questionnaire with participants also given the option to partake in a semi structured interview to further elaborate on their experiences during the COVID-19 pandemic.

Results: The patient questionnaire and the semi structured interview yielded 30 and 5 responses respectively. No sophisticated data analysis has been completed, however preliminary findings have shown that patients are highly satisfied with the provision of care despite the necessary changes imposed by the COVID-19 restrictions. Contrary to this, clinical outcomes as reported by the patients do not reflect such a positive trend, with many patients living with their diabetic foot ulcerations much longer than the norm as stated by the literature. Loneliness and social isolation were the most common

Conclusions: The relocation of more services out to the community were positively welcomed by service users however the patient self-reported outcomes do not correspond. This highlights the need for improved community-based care which would also help disburden the overcrowded hospital clinics.

Results: An overview of the results are provided in table 1, figures 1 and 2.

Results: Figure 1 represents episodes following cross referencing LTHT electronic health records with NDFA data. This was then repeated following service changes to facilitate improvements. This factored a 94% improvement.

Conclusions: The audit supports improvements were necessary to increase ascertainment and reliability.

Background: To report patient and health care practitioner (HCP) experiences in the use of a hands-free single crutch (HFSC) as a novel therapy in the post-operative rehabilitation of diabetes related foot complaints. This is a removable device that can be attached to the thigh and transmits weight through a flexed knee. This enables the individual to remain independently mobile and not bear weight through the injured foot.

Methods: Over 18-months, six inpatients chose to self-purchase an HFSC for use in their post-operative rehabilitation. These patients selected this device as it maintained their independence in mobility and was an alternative to the housebound, non-weight-bearing, microenvironment advised for their recovery. During inpatient therapy, an ability to mobilise along a 100-metre walkway with the HFSC was undertaken before discharge to ensure patient safety in mobilisation.

Results: Within this cohort, 83% were male, 67% had Type 2 Diabetes, age (mean±SD) 55±11 years and HbA1c (mean±SD) 81±26 mmol/mol. Pre-admission, all patients were fully weight-bearing independently except for one who was performing standing transfers only. The reason for admission were three elective reconstructions, two emergency minor lower extremity amputations and one for calcaneal osteomyelitis.

Conclusions: This observational case series using the HFSC as a novel therapy requested by patients in the post-operative rehabilitation of diabetes-related foot complaints found mixed results. HCPs should be aware of its strengths and limitations.

Background: COVID-19 lockdown resulted in reduced NHS Podiatric service provision in several treatment centres. We hypothesised that in a single centre, despite high-risk services remaining available, a reduction in multidisciplinary consultation or clinical outcome for people at higher risk of amputation could result because of wider service restriction. This service evaluation aimed to quantitatively investigate multi-disciplinary team referral differences between March-July 2019 and March-July 2020 and qualitatively explore root causes of below knee amputation in a single 2020 case-based example.

Methods: A two-stage, mixed methods, evaluation of 1) Diabetic foot MDT referral within a single South-England NHS centre was carried out between 2019 and 2020, and 2) a case-based root cause analysis. Outcome variables included SINBAD score (0-6), clinician-defined ulcer aetiology (0-3), vascular status (0-2), neurological status (0-1) and reason for referral. Tests of statistical difference or association were completed using Mann-Whitney U-test or Pearson’s Chi-square analysis. An RCA case exemplar was randomly selected from the 2020 cohort. Data triangulation was undertaken to determine potentially modifiable factors to case or cohort outcomes.

Results: In 2019 and 2020, 414 and 284 referrals were made respectively (40% reduction). There was a significant decrease in the percentage of patients whose primary reason was recorded as “other” in 2020 compared to 2019 (p=0.008). The mean SINBAD score was significantly higher for referrals in 2020 than 2019 (p=0.019). Reduced shared decision-making in care during COVID-19 restrictions was identified as possibly contributing to poorer clinical outcomes.

Conclusions: COVID-19 allowed us to investigate how disruption to breadth of podiatric service provision can impact patient outcomes. Our evaluation has quantified a reduction in high-risk case MDT referral, a worsening in foot health at the point of referral, and uncovered a negative impact upon shared decision-making. This highlights important considerations for Podiatric service design post–COVID-19.

Background: A poster presentation outlining anatomy, definition, aetiology, pathophysiology and surgical management options.

Methods: Case presentation with clinical pictures and X-Rays; pre op, post op, and at 6 weeks.

Results: The case highlights a management option to a common clinical problem encountered in patients who have diabetes that can cause recurrent ulceration and resultant morbidity.

Conclusions: The case was referred from our community podiatry team and serves as an example of how podiatrists and podiatric surgery teams can work synergistically to offer solutions to potentially limb threatening conditions.

Background: Dystonia of the foot and ankle is a life altering condition and a rare presentation in podiatry clinics.

Methods: Between 2014-21 four such conditions presented in a private podiatry context, were successfully treated, the outcomes of which fed into 7 years of reflective practice, in turn driving and guiding development of a novel passive stimulus approach to their treatment: Neurospecific Foot Mobilisation (NSM).

Results: NSM is primarily a tissue mobilisation intending to target Ruffini afferents, classed as Slow Adapting type 2 (SA2), within the cutaneous and fascial tissues of the plantar medial foot arch and ankle retinacula. To move this approach into possible pilot studies there is need to establish, at minimum, a neurobiological plausibility to underpin it. That is, there is presence of relevant afferents with neuromodulating capacity in the mobilised tissues. Drawing on cutaneous and muscle microneurography, neuroanatomy of fascia, current concepts of Manual Therapy (MT) and case reflection, this poster explores such a possibility.

Conclusions: NSM’s gentle application serves as a standalone treatment or as part of a multimodal care pathway. It is proposed as a specific BIO within the Biopsychosocial framework. To date, a search of the literature has not brought up a similar reported approach nor associated outcomes.

Background: Elastic ‘kinesiology’ tape is commonly used in the management of acute and chronic musculoskeletal disorders. The therapeutic action of elastic tape occurs when tape is applied to the skin under different percentages of stretch, contracting on the skin, creating wrinkles in the skin layers and fascia and theoretically decompressing deeper structures e.g. muscle tissue. As plantar foot epidermis is thicker than non-weight bearing epidermis e.g. on the lateral side of the leg then, is the contractility of the tape affected when applied to different thicknesses of skin

Results: Using a one-tailed paired t – test, significance level p<0.05, it was inferred that there is a highly statistically significant difference in contractility of the tape, the amount of contraction of elastic tape was greater on the thinner lateral skin than on the thicker plantar skin (mean difference = 0.35cm, t = -7.92, 95% Confidence Interval: 0.26 to 0.45cm, p<0.00001)

Conclusions: Elastic tape exhibits a greater contraction from full stretch when applied to thinner skin compared to thicker skin.

Background: It has been identified through staff survey and focus groups that although HDFT Podiatry Services provides a widely acknowledged induction and preceptorship package for new graduates there is a lack of structure in mentorship and career development strategies for established clinicians. Little training is dedicated in preparing clinicians to become mentors themselves.

Methods: A development day was help with Band 7s across the service. A standardised mentorship framework was developed to ensure all staff, regardless of Band or aspiration have access to the same support. Standard operating procedures and mentorship contracts were devised.

Results: The framework was rolled out service wide in October 2019. Regular updates and training days are to be held to support those delivering the support. Initial feedback indicates a positive effect of recruitment, retention and morale. Clinicians feel well supported and Band 7s feel empowered within their leadership roles.

Conclusions: Ongoing work is to be done to continue to evaluate and develop the program

Background: Addressing shortages for podiatrists is a goal of the NHS Long Term plan. However, in recent years there has been reductions in the numbers choosing to study the subject in the UK. The aim of this research was to understand students’ motivations for choosing a podiatry career, their sources of influence and barriers to entry. Understanding career decision-making processes will inform healthcare career promotion and advice for podiatry courses.

Methods: An online questionnaire was disseminated to podiatry students in England between February and March 2021. This comprised demographic and Likert scale questions, with open-ended questions about public perception of podiatry and advice to individuals interested in the profession. Descriptive analysis was applied to the data.

Results: The questionnaire was completed by 115 podiatry students. Female students comprised 87% of the respondents and 75% of respondents were white. Of the sample, 38% were under 25. Choosing podiatry to improve the quality of life for a patient/service user was the most influential motivation. The biggest source of influence on selecting a podiatry career was from conducting their own research. Misconceptions around the profession and what the role involves was seen as the most significant barrier to choosing the career.

Conclusions: As has been highlighted in other studies, a lack of awareness and information about podiatry were identified as the key barriers to choosing podiatry. This was evident in personal sources of influence, such as meeting a podiatrist, as the most important sources of influence. On the whole, educational, media and marketing sources scored low in terms of influence. The findings highlight areas of investigation for future research. For example, addressing issues around misconceptions and awareness of the profession for different age groups to ensure healthcare career promotion is appropriate for each group and the use of effective sources of influence.

Background: This study was based on a University of Northampton (UoN) project within the Undergraduate and Postgraduate Research Bursaries at Northampton (URB@N) to discover the interprofessional learning experiences of current second year healthcare students.

Methods: We based our research on the Readiness for Interprofessional Learning Scale (RIPLS) Questionnaire and adapted it to gather specific qualitative feedback on their experiences during first and second year at UoN.

Conclusions: Overall the feedback received highlighted that students have an interest in getting to know their future work colleagues and in gaining a better understanding of the diverse roles of each profession which contributes to the overall holistic approach to client care. From this the faculty are going to devise a learning resource for current second years during their third year to prepare them for interprofessional working in the workplace.

Background: The COVID-19 pandemic had a devastating effect on clinical teaching and clinical placement opportunities in all health professions but allowed us an opportunity to rethink traditional methods of clinical education and to consider how we could still offer a meaningful clinical teaching and placement experience for students using digital technology.

Methods: The initial aim was for a virtual clinical placement to be developed using head camera technology. This would allow students to undertake observational clinical teaching sessions regardless of the number of students, placement providers or future disruptions to normal provision. The head cameras chosen for use are fully voice activated, are robust and can be cleaned so eliminating issues with infection control.

Results: The chosen head camera technology is clear, can record and take photographs and has a built-in two-way audio. The real advantage to this system, however, is that the head camera can be linked to Microsoft TEAMs, a reliable platform that we and our students have been using throughout the pandemic. We are extremely fortunate to have several podiatry departments from local NHS trusts onboard to assist with the first stages of this project.

Conclusions: Although yet to incorporate this technology formally into the curriculum, we envisage that it will further expand placement opportunities for students by allowing them to remotely access other clinical professions such as vascular services and podiatric surgery teams. There is an acknowledgement however that no matter how good the virtual placement provision is, it is never intended to fully replace face to face patient encounters and hands-on practical work, but to enhance and expand current provision – future proofing the clinical educational experience.