Developing a best practice approach to real time clinical gait analysis as part of a clinical musculoskeletal assessment in the treatment of non-neurological lower limb symptoms in adults

The purpose of real time clinical gait analysis (RTCGA) is to aid in diagnosis of musculoskeletal (MSK) conditions, determine treatment goals and evaluate treatment outcomes. Clinicians are recommended to conduct RTCGA as part of a lower limb MSK non-neurological adult patient assessment. The timely and accurate use of such a diagnostic method, with the smallest possibility of a missed diagnosis or misdiagnosis, is crucial in the treatment of any disease or disorder. Despite this, there remains little MSK RTCGA evidence to support the methods by which to do so. This PhD reflects a programme of work which was undertaken to develop a best practice RTCGA approach for adult non-neurological lower limb MSK injury. The research aim was to establish a best practice approach for RTCGA to be used as part of a clinical MSK assessment in the treatment of non-neurological lower limb symptoms in adults. This doctoral thesis programme of work employed a mixed methods approach, involving a series of deductive quantitative investigations followed by inductive qualitative investigation. Deductive quantitative investigation involved scoping of the RTCGA best practice approach via narrative literature review, a patient and public involvement and engagement (PPIE) exercise and preclinical testing. A systematic review was conducted to robustly establish available MSK RTCGA literature. Inductive, qualitative investigation involved exploration of MSK podiatrists’ views and experiences of RTCGA for an exemplar condition, posterior tibial tendon dysfunction (PTTD), using thematic analysis of semi-structured interviews. Findings supplied the foundation by which preliminary clinical recommendations for a MSK RTCGA best practice approach were created. A preliminary objective RTCGA instrument was created. Scenario testing for face validity demonstrated this preliminary RTCGA instrument would not detect kinematic changes following intervention, and an additional immediate intervention RTCGA instrument was developed. The resultant preliminary RTCGA instrument, which was then subject to preclinical testing, consisted of 2 sections, the RTCGA instrument score and the RTCGA immediate intervention score. Preclinical investigations demonstrated difficulties in the ability to test the preliminary RTCGA instrument for both reliability and validity. Literature review and searches from narrative, systematic and PPIE investigations found a lack of high-level evidence and guidance for the use of RTCGA and the development of RTCGA best practice approaches. In total, 6 substantial problems were encountered associated with the creation of an objective quantifiable instrument as a RTCGA best practice approach. These were a lack of existing RTCGA knowledge; developer bias; the necessity to include shod gait assessment; a lack of normative kinematic data; the length and complexity of the preliminary RTCGA instrument and an inability to transiently alter kinematics and obtain valid data for testing. These issues deemed the continued development of an objective quantifiable RTCGA instrument to be counterproductive. To understand the conundrum that an objective quantifiable RTCGA was not feasible yet is an approach suggested for use by clinicians (notably podiatrists) as an embedded component of their practice, the exploration of MSK clinician views and experiences of RTCGA was sought prior to attempting any further development. The resultant exploratory qualitative investigation confirmed that use of RTCGA was valued by MSK podiatrists, but that no consistent systematic approach for RTCGA was available. Based upon these findings, a set of 4 core recommendations are proposed as a preliminary best practice RTCGA approach when assessing and treating adult PTTD (the GAIT assessment). These are: Get a diagnosis (recommendation 1). RTCGA should be conducted after a provisional clinical PTTD diagnosis has been proposed. Assess walking (recommendation 2). RTCGA should be used to aid in clinical diagnosis of adult patients with PTTD. Assessment should include a) essential kinematic observations, and b) dynamic presentation of pain. Intervene and assess (recommendation 3). RTCGA should be performed after a clinical intervention, such as the fitting of foot orthoses or footwear, to observe any kinematic changes. If fitting foot orthoses, it should also be used to assess for patient perceived comfort. Teach using clinical experience (recommendation 4). RTCGA education should be addressed through an experiential approach, such as small group practical teaching and clinical mentoring. The research undertaken in this doctoral thesis programme of work is the first to apply development frameworks and methods in the attempt to establish a mechanism to record gait and gait changes within a MSK clinical setting, without the aid of computerised or video recording technology. A preliminary RTCGA best practice approach has been produced that supplies guidance for MSK podiatrists, in the form of the GAIT assessment, to aid in the clinical treatment and assessment of PTTD. However, the pathway to achieving a robust clinical practice guideline requires more work. The lack of objective kinematic data for this field was a significant barrier to investigating and improving reliability and validity of RTCGA observations. RTCGA, as an aid in the diagnosis and treatment of MSK injury, is arguably a high-level skill associated with professional specialisation. It follows, therefore, that such a skill would be supported by objectivity and standardisation of practice, yet the lack of normative data for RTCGA continues to act as a barrier to this. A new approach in which RTCGA is focussed on the patient symptoms and evidence based observation is proposed

Developing a best practice approach to real time clinical gait analysis as part of a clinical musculoskeletal assessment in the treatment of nonneurological lower limb symptoms in adult

The purpose of real time clinical gait analysis (RTCGA) is to aid in diagnosis of musculoskeletal (MSK) conditions, determine treatment goals and evaluate treatment outcomes. Clinicians are recommended to conduct RTCGA as part of a lower limb MSK non-neurological adult patient assessment. The timely and accurate use of such a diagnostic method, with the smallest possibility of a missed diagnosis or misdiagnosis, is crucial in the treatment of any disease or disorder. Despite this, there remains little MSK RTCGA evidence to support the methods by which to do so. This PhD reflects a programme of work which was undertaken to develop a best practice RTCGA approach for adult non-neurological lower limb MSK injury. The research aim was to establish a best practice approach for RTCGA to be used as part of a clinical MSK assessment in the treatment of non-neurological lower limb symptoms in adults. This doctoral thesis programme of work employed a mixed methods approach, involving a series of deductive quantitative investigations followed by inductive qualitative investigation. Deductive quantitative investigation involved scoping of the RTCGA best practice approach via narrative literature review, a patient and public involvement and engagement (PPIE) exercise and preclinical testing. A systematic review was conducted to robustly establish available MSK RTCGA literature. Inductive, qualitative investigation involved exploration of MSK podiatrists’ views and experiences of RTCGA for an exemplar condition, posterior tibial tendon dysfunction (PTTD), using thematic analysis of semi-structured interviews. Findings supplied the foundation by which preliminary clinical recommendations for a MSK RTCGA best practice approach were created. A preliminary objective RTCGA instrument was created. Scenario testing for face validity demonstrated this preliminary RTCGA instrument would not detect kinematic changes following intervention, and an additional immediate intervention RTCGA instrument was developed. The resultant preliminary RTCGA instrument, which was then subject to preclinical testing, consisted of 2 sections, the RTCGA instrument score and the RTCGA immediate intervention score. Preclinical investigations demonstrated difficulties in the ability to test the preliminary RTCGA instrument for both reliability and validity. Literature review and searches from narrative, systematic and PPIE investigations found a lack of high-level evidence and guidance for the use of RTCGA and the development of RTCGA best practice approaches. In total, 6 substantial problems were encountered associated with the creation of an objective quantifiable instrument as a RTCGA best practice approach. These were a lack of existing RTCGA knowledge; developer bias; the necessity to include shod gait assessment; a lack of normative kinematic data; the length and complexity of the preliminary RTCGA instrument and an inability to transiently alter kinematics and obtain valid data for testing. These issues deemed the continued development of an objective quantifiable RTCGA instrument to be counterproductive. To understand the conundrum that an objective quantifiable RTCGA was not feasible yet is an approach suggested for use by clinicians (notably podiatrists) as an embedded component of their practice, the exploration of MSK clinician views and experiences of RTCGA was sought prior to attempting any further development. The resultant exploratory qualitative investigation confirmed that use of RTCGA was valued by MSK podiatrists, but that no consistent systematic approach for RTCGA was available. Based upon these findings, a set of 4 core recommendations are proposed as a preliminary best practice RTCGA approach when assessing and treating adult PTTD (the GAIT assessment). These are: Get a diagnosis (recommendation 1). RTCGA should be conducted after a provisional clinical PTTD diagnosis has been proposed. Assess walking (recommendation 2). RTCGA should be used to aid in clinical diagnosis of adult patients with PTTD. Assessment should include a) essential kinematic observations, and b) dynamic presentation of pain. Intervene and assess (recommendation 3). RTCGA should be performed after a clinical intervention, such as the fitting of foot orthoses or footwear, to observe any kinematic changes. If fitting foot orthoses, it should also be used to assess for patient perceived comfort. Teach using clinical experience (recommendation 4). RTCGA education should be addressed through an experiential approach, such as small group practical teaching and clinical mentoring. The research undertaken in this doctoral thesis programme of work is the first to apply development frameworks and methods in the attempt to establish a mechanism to record gait and gait changes within a MSK clinical setting, without the aid of computerised or video recording technology. A preliminary RTCGA best practice approach has been produced that supplies guidance for MSK podiatrists, in the form of the GAIT assessment, to aid in the clinical treatment and assessment of PTTD. However, the pathway to achieving a robust clinical practice guideline requires more work. The lack of objective kinematic data for this field was a significant barrier to investigating and improving reliability and validity of RTCGA observations. RTCGA, as an aid in the diagnosis and treatment of MSK injury, is arguably a high-level skill associated with professional specialisation. It follows, therefore, that such a skill would be supported by objectivity and standardisation of practice, yet the lack of normative data for RTCGA continues to act as a barrier to this. A new approach in which RTCGA is focussed on the patient symptoms and evidence-based observation is proposed

Real time non-instrumented clinical gait analysis as part of a clinical musculoskeletal assessment in the treatment of lower limb symptoms in adults: A systematic review

Background:The aim of this review was to evaluate and summarise the current evidence on non-computerised or non-recorded real time adult gait assessment conducted within the clinical musculoskeletal setting. It was hoped a protocol for best practice and a framework for further research could be developed from this search.Research question:Can a protocol for best practice and a framework for further research be established from previous literature relating to non-computerised or non-recorded real time adult gait analysis in a musculoskeletal clinical setting.Methods:A literature review with no limitation on date of publication was conducted on the 18th February 2017.Results:The review found no significantly informative papers relating to the searchSignificance:The lack of research on the accuracy, reliability and therefore worth of this highly recommended area of musculoskeletal assessment raises concerns over current assessment and treatment pathways. Further work to develop a method by which gait analysis can be routinely employed in musculoskeletal clinics as a diagnostic tool is required, with any new approach undertaking robust methodological testing

If It doesn't work, why do we still do it? The continuing use of subtalar joint neutral theory in the face of overpowering critical research

The use of subtalar joint neutral (STJN) in the assessment and treatment of foot-related musculoskeletal symptomology is common in daily practice and still widely taught. The main pioneer of this theory was Dr Merton L. Root, and it has been labeled with a variety of names: “the foot morphology theory,” “the subtalar joint neutral theory,” or simply “Rootian theory” or “Root model.” The theory's core concepts still underpin a common approach to musculoskeletal assessment of the foot, as well as the consequent design of foot orthoses. The available literature continues to point to Dr Root's theory as the most prevalently utilized. Concurrently, the worth of this theory has been challenged due to its poor reliability and limited external validity. This Viewpoint reviews the main clinical areas of the STJN theory, and concludes with a possible explanation and concerns for its ongoing use. To support our view, we will discuss (1) historical inaccuracies, (2) challenges with reliability, and (3) concerns with validity

Podiatrists’ views and experiences of using real time clinical gait analysis in the assessment and treatment of posterior tibial tendon dysfunction

Background: real time clinical gait analysis (RTCGA) is often incorporated as part of a general or lower limb musculoskeletal (MSK) adult patient assessment. However, it is not known if RTCGA is clinically effective as a useful outcome measure or aids in decision making. Whether there is a clinical worth in conducting RTCGA in adult MSK consultations remains controversial. The aim of this study was to provide unique insights into MSK podiatrists use and opinions of RTCGA, using Posterior Tibial Tendon Dysfunction (PTTD) as an exemplar adult condition.Methods: a qualitative approach was employed to explore MSK podiatrists’ views and experiences of RTCGA when assessing or treating patients with PTTD. Semi-structured interviews were conducted via Skype video calls which were transcribed using an orthographic transcription method. Thematic analysis was employed to identify key meanings and report patterns within the data.Results: twenty nine MSK podiatrists who used RTCGA in the assessment and treatment of PTTD participated in the study. Five themes were identified as 1) RTCGA Method; 2) Working with RTCGA; 3) RTCGA uses; 4) What could aid RTCGA; 5) How RTCGA skills are acquired. This is the first known study to explore this topic of relevance to clinicians and researchers alike. Clinical observations were not only kinematic, but also included patient perceived experiences such as pain and orthotic comfort with normative kinematic reference values not perceived as important to that management goal. The most common barefoot RTCGA observations performed were the rearfoot to leg angle, medial bulge, forefoot abduction and arch integrity. However, a high amount of variation in many gait observations was noted between participants. Documentation methods also varied with a four-point scale system to grade motion and position most often employed and RTCGA was most often learnt through experience. The main barriers to performing RTCGA were clinical time and space restrictions.Conclusion: findings from this study have provided a view of how podiatry MSK clinicians utilise RTCGA within their practice. MSK podiatrists use RTCGA as both an outcome measure and as an aid in decision making. This implies a perceived worth in conducting RTCGA, however further work is recommended that focusses on development of a national guideline to RTCGA to be adopted

The GAIT assessment

A real-time clinical gait analysis approach can aid in the assessment and treatmentof posterior tibial tendon dysfunction, developing and implementing best practice in the environment of poor evidencebase and charismatic authority

Control and Measurement of Plasma pH in Equilibrium Dialysis: Influence on Drug Plasma Protein Binding

ABSTRACT: Past publications have highlighted the influence of postdialysis plasma pH on the measured fraction unbound in plasma (fup). There is disparity in the industry as to which of two main methods is more suitable for controlling postdialysis plasma pH: the use of either a stronger buffer or a CO 2 atmosphere for the incubation. In the current study, it has been found that 10% CO 2 could be too high for the buffering capacities of both 100 mM sodium phosphate (pH 7.40 decreased to pH 6.90 after a 6-h incubation) and plasma (decreased below pH 7.40 after a 6-h incubation). To provide appropriate control over the postdialysis plasma pH, for a range of species, it is proposed that a standard phosphate buffer strength (100 mM) and pH (7.40) in combination with a 5% CO 2 atmosphere be used for equilibrium dialysis. Furthermore, statistically significant differences in fup values obtained with a pH difference of less than 0.32 pH unit have been demonstrated. An acceptance range for postdialysis plasma pH in routine in vitro fup screening assays of pH 7.40 ؎ 0.10 is recommended

The control and measurement of plasma pH in equilibrium dialysis; influence on drug plasma protein binding DMD # 36988 2 RUNNING TITLE: Plasma pH control in equilibrium dialysis

Abstract Past publications have highlighted the influence of post-dialysis plasma pH on the measured fraction unbound in plasma (fup). There is disparity in the industry as to which of two main methods is more suitable for controlling post-dialysis plasma pH; the use of either a stronger buffer or a CO 2 atmosphere for the incubation. In the current study, it has been found that 10% CO 2 could be too high for the buffering capacities of both 100 mM sodium phosphate (pH 7.40 decreased to pH 6.90 after 6 h incubation) and plasma (decreased below pH 7.40 after 6 h incubation). In order to provide appropriate control over the post-dialysis plasma pH, for a range of species, it is proposed that a standard phosphate buffer strength (100 mM) and pH (7.40) in combination with a 5% CO 2 atmosphere is utilised for equilibrium dialysis. Furthermore, statistically significant differences in fup values obtained with a pH difference of less than 0.32 pH unit have been demonstrated. An acceptance range for post-dialysis plasma pH in routine in vitro fup screening assays of pH 7.40 ± 0.10 is recommended