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Integrating Research Into the Clinic
What Evidence Based Practice Means to the Practising Podiatrist
This paper is the first in a series of three aimed at introducing clinicians to current concepts in research, and outlining how they may be able to apply these concepts to their own clinical practice. It has become evident in recent years that while many practitioners may not want to become actively involved in the research process, simply keeping abreast of the burgeoning publication base will create new demands on their time, and will often require the acquisition of new skills.
This series introduces the philosophies of integrating what sometimes may appear to be abstract research into the realities of the clinical environment. It will provide practitioners with an accessible summary of the tools required in order to understand the research process. For some, it is hoped this series may provide some impetus for the contemplative practitioner to become a more active participant in the research process. This first paper addresses how the evidence based practice (EBP) revolution can be used to empower the individual practitioner and how good quality evidence can improve the overall clinical decision making process. It also suggests key strategies by which the clinician may try to enhance their clinical decision making process and make research evidence more applicable to their day to day clinical practice. (J Am Podiatr Med Assoc 92(2): 115-122, 2002)
Wound Healing and Infection in Nail Matrix Phenolization Wounds
Does Topical Medication Make a Difference?
After nail matrix ablation using phenolization, a medicated wound dressing (10% povidone iodine), an amorphous hydrogel dressing (Intrasite Gel), and a control dressing (paraffin gauze) were evaluated. Forty-two participants, randomly divided into three dressing groups, were evaluated. Healing time did not differ between the 10% povidone iodine (33 days), amorphous hydrogel (33 days), and the control dressing (34 days). For all groups, the clinical infection rate was lower than in previous studies, and there was no clinical difference between groups (one infection in the povidone iodine and control groups; none in the amorphous hydrogel group). However, in the amorphous hydrogel group, other complications, such as hypergranulation, were more likely. This investigation indicated that medicated or hydrogel dressings did not enhance the rate of healing or decrease infection rates. (J Am Podiatr Med Assoc 91(5): 230-233, 2001)
Clinicians often use foot orthoses to manage the symptoms of plantar fasciitis. Although there has been considerable research evaluating the effectiveness of orthoses for this condition, there is still a lack of scientific evidence that is of suitable quality to fully inform clinical practice. Randomized controlled trials are recognized as the “gold standard” when evaluating the effectiveness of treatments. We discuss why randomized controlled trials are so important, the features of a well-conducted randomized controlled trial, and some of the problems that arise when trial design is not sound. We then evaluate the available evidence for the use of foot orthoses, with particular focus on published randomized controlled trials. From the evidence to date, it seems that foot orthoses do have a role in the management of plantar fasciitis and that prefabricated orthoses are a worthwhile initial management strategy. At this time, however, it is not possible to recommend either prefabricated or customized orthoses as being better, and it cannot be inferred that customized orthoses are more effective over time and therefore have a cost advantage. Additional good-quality randomized controlled trials are needed to answer these questions. (J Am Podiatr Med Assoc 94(6): 542–549, 2004)
High-Dye and low-Dye taping are commonly used by clinicians to treat a variety of foot and ankle pathologies, particularly those associated with excessive rearfoot pronation. While the effects of taping on end range of motion have been extensively studied, relatively little is understood about the effect of the two styles of taping on rearfoot motion. Eighteen participants were analyzed in three conditions: 1) barefoot, 2) with high-Dye taping, and 3) with low-Dye taping. Two-dimensional motion of the rearfoot was assessed for each condition. The results indicated maximum inversion was increased with both high-Dye and low-Dye taping as compared with no taping. Only high-Dye taping, however, significantly reduced the maximum eversion of the rearfoot. The results suggest that high-Dye taping is an appropriate taping choice when control of eversion of the rearfoot is desired. (J Am Podiatr Med Assoc 91(5): 255-261, 2001)
Some clinicians may feel dissociated from, and intimidated by the ever-increasing emphasis on research. However, with an understanding of some of the basic principles and key terms, research can feel less daunting. It is the aim of this article, the second in a series of three focusing on understanding research, to introduce clinicians to the different approaches to research, to improve understanding of what the approaches mean, and to highlight when a particular approach may be appropriate. Furthermore, the article will provide an explanation of some of the common terms used within clinical research. This should aid the clinician in applying good, simple, scientific principles to evaluating clinical research evidence. (J Am Podiatr Med Assoc 92(3): 159-169, 2002)
Abnormal foot morphology has been suggested to contribute to overuse injuries in athletes. This study investigated the relationship between foot type and injury incidence in a large sample of competitive triathletes not wearing foot orthoses during a 6-month retrospective analysis and a 10-week prospective cohort study. Foot alignment was measured using the Foot Posture Index and the Valgus Index, and participants were assigned to supinated, pronated, and normal foot-type groups. Overall, 131 triathletes sustained 155 injuries during the study. Generally, foot type was not a major risk factor for injury; however, there was a fourfold increased risk of overuse injury during the competition season in athletes with a supinated foot type. The results of this study show that triathletes with a supinated foot type are more likely to sustain an overuse injury. (J Am Podiatr Med Assoc 95(3): 235–241, 2005)
This research project investigated the orthotic prescription habits of podiatric physicians in Australia and New Zealand. A 23-item questionnaire was distributed to all members of the Australian Podiatry Association and the New Zealand Society of Podiatrists. When asked what type of foot orthoses they prescribe most often, 72% of respondents reported functional foot orthoses; the next most common response was prefabricated orthoses (12%). A typical prescription for functional foot orthoses consisted of a modified Root style orthosis, balanced to the neutral calcaneal stance position, with the shell made from polypropylene and an ethyl vinyl acetate (EVA) rearfoot post applied. The majority of podiatric physicians surveyed used a commercial orthotic laboratory to fabricate their orthoses. However, New Zealand respondents were three times more likely to prescribe prefabricated foot orthoses, and males were twice as likely as females to manufacture the orthoses themselves rather than use a commercial orthotic laboratory. (J Am Podiatr Med Assoc 91(4): 174-183, 2001)
Understanding Statistics
Putting P-Values into Perspective
Understanding statistics can be one of the more difficult and daunting tasks facing the clinician attempting to understand and use the research literature. While the fundamental aim of including statistics in literature is to justify the conclusions and to enhance the information presented, all too often, statistics serve only to intimidate and alienate clinicians. There are two sources for this barrier to understanding: poor comprehension of statistics by clinicians, and inappropriate presentation of statistics by researchers. In the third of our papers on evidence-based practice and the clinician, some basic principles of statistics are introduced. Aspects such as the concepts of clinical and statistical significance are discussed, and an outline of the appropriate use of specific statistics is provided. The hope is that this will enable the clinician to better judge the applicability of statistical techniques as applied in the published literature. Some of the newer, more ‘clinician friendly’ statistical approaches are also presented. Finally some of the cheats and shortcuts commonly encountered in the presentation of research are discussed, and the methods for dealing with them are outlined. (J Am Podiatr Med Assoc 92(5): 297-305, 2002)
Low-Dye taping is often used as a short-term treatment for plantar fasciitis. We evaluated the short-term effectiveness of low-Dye taping in relieving pain associated with plantar fasciitis. In this comparative study conducted at a university-based clinic, 65 participants with plantar fasciitis who received low-Dye taping for 3 to 5 days were compared with 40 participants who did not receive taping. Pain before and after treatment was measured using a visual analog pain scale. Analysis of the data was by the intention-to-treat principle, and a linear regression approach to analysis of covariance was used to compare effects. The visual analog pain scale score improved by a mean of 20 mm (from 44 to 24 mm) in the taping group and worsened by a mean of 6 mm (from 51 to 57 mm) in the control group. The analysis of covariance–adjusted difference in therapeutic effect favored the taping group by 31.7 mm (95% confidence interval, 23.6–39.9 mm) and was statistically significant (t = 7.71). In the short term, low-Dye taping significantly reduces the pain associated with plantar fasciitis. These findings are the first quantitative results to demonstrate the significant therapeutic effect of this treatment modality in relieving the symptoms associated with plantar fasciitis. (J Am Podiatr Med Assoc 95(6): 525–530, 2005)
