Analyzing Second Stage Ecological Regressions: Comment on Herron and Shotts

Statistic

Deep Posterior Compartment Strength and Foot Kinematics in Subjects with Stage II Posterior Tibial Tendon Dysfunction

Background: Tibialis posterior muscle weakness has been documented in subjects with Stage II posterior tibial tendon dysfunction (PTTD) but the effect of weakness on foot structure remains unclear. The association between strength and flatfoot kinematics may guide treatment such as the use of strengthening programs targeting the tibialis posterior muscle. Materials and Methods: Thirty Stage II PTTD subjects (age; 58.1 ± 10.5 years, BMI 30.6 ± 5.4) and 15 matched controls (age; 56.5 ± 7.7 years, BMI 30.6 ± 3.6) volunteered for this study. Deep Posterior Compartment strength was measured from both legs of each subject and the strength ratio was used to compare each subject\u27s involved side to their uninvolved side. A 20% deficit was defined, a priori, to define two groups of subjects with PTTD. The strength ratio for each group averaged; 1.06 ± 0.1 (range 0.87 to 1.36) for controls, 1.06 ± 0.1 (range, 0.89 to 1.25), for the PTTD strong group, and 0.64 ± 0.2 (range 0.42 to 0.76) for the PTTD weak group. Across four phases of stance, kinematic measures of flatfoot were compared between the three groups using a two-way mixed effect ANOVA model repeated for each kinematic variable. Results: Subjects with PTTD regardless of group demonstrated significantly greater hindfoot eversion compared to controls. Subjects with PTTD who were weak demonstrated greater hindfoot eversion compared to subjects with PTTD who were strong. For forefoot abduction and MLA angles the differences between groups depended on the phase of stance with significant differences between each group observed at the pre-swing phase of stance. Conclusion: Strength was associated with the degree of flatfoot deformity observed during walking, however, flatfoot deformity may also occur without strength deficits. Clinical Relevance: Strengthening programs may only partially correct flatfoot kinematics while other clinical interventions such as bracing or surgery may also be indicated

The global diffusion of environmental clubs: how pressure from importing countries supports the chemical industry's Responsible Care® program

Environmental clubs have proliferated across sectors and issue areas. We examine the diffusion of the chemical industry's Responsible Care® (RC) program. Much of the work on the diffusion of clubs has focused on the demand side: why firms join these clubs despite the costs of doing so. There is some work focusing on the supply side: why actors establish or create a new club. However, there is virtually no work examining why national-level industry associations decide to subscribe to an existing global environmental club in order to make it available to their members. Industry organizations in 17 lower and middle-income countries have joined RC, comprising 25 percent of RC members. We ask, in the context of developing countries, what motivates national associations to join RC? Drawing on an original dataset of RC global diffusion in 195 countries (1985–2017), we estimate a Cox proportional hazards model of the risk of joining RC. We find that RC adoption is more likely when a country exports chemicals to other countries that have joined RC (the California effect) and is unaffected by the total volume of its chemical trade. Thus, while exposure to global markets per se may not influence RC adoption, incentives change considerably when countries’ key importers signal their support for these environmental practices. This is because importing firms often realize that because they have joined Responsible Care, NGOs and stakeholders expect them to demand that their overseas suppliers adopt the same sort of environmental policies and work place safety practices. In addition, peer pressure and learning matter: RC adoption is more likely when countries in close physical vicinity (e.g., within 500 miles) have joined the club. Finally, domestic factors play a role as well: both the level of democracy and the size of the economy encourage national associations to join RC

Randomized Controlled Trial Comparing Orthosis Augmented by Either Stretching or Stretching and Strengthening for Stage II Tibialis Posterior Tendon Dysfunction

Background: The value of strengthening and stretching exercises combined with orthosis treatment in a home-based program has not been evaluated. The purpose of this study was to compare the effects of augmenting orthosis treatment with either stretching or a combination of stretching and strengthening in participants with stage II tibialis posterior tendon dysfunction (TPTD). Methods: Participants included 39 patients with stage II TPTD who were recruited from a medical center and then randomly assigned to a strengthening or stretching treatment group. Excluding 3 dropouts, there were 19 participants in the strengthening group and 17 in the stretching group. The stretching treatment consisted of a prefabricated orthosis used in conjunction with stretching exercises. The strengthening treatment consisted of a prefabricated orthosis used in conjunction with the stretching and strengthening exercises. The main outcome measures were self-report (ie, Foot Function Index and Short Musculoskeletal Function Assessment) and isometric deep posterior compartment strength. Two-way analysis of variance was used to test for differences between groups at 6 and 12 weeks after starting the exercise programs. Results: Both groups significantly improved in pain and function over the 12-week trial period. The self-report measures showed minimal differences between the treatment groups. There were no differences in isometric deep posterior compartment strength. Conclusions: A moderate-intensity, home-based exercise program was minimally effective in augmenting orthosis wear alone in participants with stage II TPTD. Level of Evidence: Level I, prospective randomized study

The Relationship Between Ankle, Hindfoot, and Forefoot Position and Posterior Tibial Muscle Excursion

Background: The purpose of this study was to examine the relationship of forefoot position in the transverse plane (abduction/adduction), hindfoot position in the frontal plane (eversion/inversion), and ankle position in the sagittal plane (plantarflexion/dorsiflexion) with posterior tibialis (PT) muscle excursion using an in vitro cadaver model. Methods: Seven fresh-frozen cadaver specimens were potted and mounted on a frame. The PT tendon was dissected 15 cm proximal to the medial malleolus, and a 5-kg weight was sutured to the tendon. A six-camera motion analysis system (Optotrak, Northern Digital, Inc.) was used to track three-dimensional (3D) motion of the tibia, calcaneus (hindfoot) and first metatarsal (forefoot) using bone pins. The ankle, hindfoot, and forefoot were manually placed in 24 different ankle and foot positions. A stepwise regression analysis was used to examine the relationship among ankle, hindfoot, and forefoot kinematics and PT muscle excursion. Results: Hindfoot eversion/inversion and forefoot abduction/adduction accounted for 77% of the variance in PT muscle excursion, with small contributions from ankle plantarflexion/dorsiflexion (5.7%) and forefoot plantarflexion/dorsiflexion (1.9%). A combined regression equation applied to individual specimens resulted in average errors of less than 2.5 mm. Conclusions: This study supports the hypothesis that PT muscle excursion can be estimated using specific foot and ankle kinematic variables. Further, these data suggest that hindfoot eversion and forefoot abduction account for most of the variance in PT muscle excursion and are theorized to be important to control clinically altering the length of the posterior tibial muscle

A Consensus on Second Stage Analyses in Ecological Inference Models

Statistic

The Effect of Stage II Posterior Tibial Tendon Dysfunction on Deep Compartment Muscle Strength: A New Strength Test

Background: The purpose of this study was to compare isometric subtalar inversion and forefoot adduction strength in subjects with Stage II posterior tibial tendon dysfunction (PTTD) to controls. Materials and Methods: Twenty four subjects with Stage II PTTD and fifteen matched controls volunteered for this study. A force transducer (Model SML- 200, Interface, Scottsdale, AZ) was connected with a resistance plate and oscilloscope (TDS 410A, Tektronix, Beaverton, OR) to the foot. Via the oscilloscope, subjects were given feedback on the amount of force produced and muscle activation of the anterior tibialis (AT) muscle. Subjects were instructed to maintain a plantar flexion force while performing a maximal voluntary subtalar inversion and forefoot adduction effort. A two-way ANOVA model with the factors including, side (involved/uninvolved) and group (control/PTTD) was used. Results: The PTTD group on the involved side showed signifi- cantly decreased subtalar inversion and foot adduction strength (0.70 ± 0.24 N/Kg) compared to the uninvolved side (0.94 ± 0.24 N/Kg) and controls (involved side = 0.99 ± 0.24 N/Kg, uninvolved side = 0.97 ± 0.21 N/Kg). The average AT activation was between 11% to 17% for both groups, however, considerable variability in subjects with PTTD. Conclusion: These data confirm a subtalar inversion and forefoot adduction strength deficit by 20% to 30% in subjects with Stage II PTTD. Although isolating the PT muscle is difficult, a test specific to subtalar inversion and forefoot adduction demonstrated the weakness in this population

Development of the infant foot as a load bearing structure : study protocol for a longitudinal evaluation (the Small Steps study)

Background An improved understanding of the structural and functional development of the paediatric foot is fundamental to a strong theoretical framework for health professionals and scientists. An infant’s transition from sitting, through crawling and cruising, to walking is when the structures and function of the foot must adapt to bearing load. The adaptation of skin and other hard and soft tissue, and foot and gait biomechanics, during this time is poorly understood. This is because data characterising the foot tissue and loading pre-walking onset does not exist. Of the existing kinematic and plantar pressure data, few studies have collected data which reflects the real-life activities of infants with modern equipment. Methods This is a longitudinal study and part of the Great Foundations Initiative, a collaborative project between the University of Brighton and the University of Salford, which is seeking to improve foot health in children. Two cohorts of 50 infants will be recruited at the two sites (University of Brighton, Eastbourne, UK and University of Salford, Salford, UK). Infants will be recruited when they first reach for their feet and attend four laboratory visits at milestones related to foot loading, with experienced independent walking being the final milestone. Data collection will include tissue characteristics (skin thickness, texture, elasticity, pH and tendon thickness and cross-sectional area), plantar pressures and kinematics captured during real world locomotion tasks. Discussion This study will provide a database characterising the development of the infant foot as it becomes a weight bearing structure. The data will allow effective comparison and quantification of changes in structure and function due to maturation and loading by measuring pre and post established walking. Additional variables which impact on the development of the foot (gender, ethnicity and body weight) will also be factored into our analysis. This will help us to advance understanding of the determinants of foot development in early childhood