https://www.um.edu.mt/library/oar/handle/123456789/49423 2026-04-27T14:39:13Z https://www.um.edu.mt/library/oar/handle/123456789/52989 Title: An investigation of clinical tests for functional hallux limitus Abstract: Aim: In clinical practice, various tests are routinely used to diagnose Functional Hallux Limitus, which to-date, have not been rigorously investigated. Thus, this study aimed to investigate the validity of the Non-Weightbearing Test (NWB), Hubscher’s manoeuvre (HM) and plantar pressure analysis, or any of their combinations, to represent first metatarsophalangeal joint (MPJ) dorsiflexion during gait. Methods: A comparative, non-experimental study design with a deductive approach was employed on 52 feet from 26 subjects. The NWB and HM were performed on the participants. Vicon® Nexus capture system with the Istituto Ortopedico Rizzoli model was used to acquire and analyse foot and ankle kinematics, whilst the TEKSCAN HR mat was used to measure peakpressures and pressure time integral for the plantar aspect of the foot. The pressure data was divided into three regions which included hallux, first metatarsal head and 2-5 metatarsal heads. Ratios between the hallux and first metatarsal head regions (HRPP and HRPTI), and between the lesser metatarsal heads and the first metatarsal head (LRPP and LRPTI) were created. Results: There was no significant difference in Maximum (p=0.296) or True (p=0.643) Hallux Dorsiflexion between participants that tested positively and negatively for the NWB test. There was also no significant difference in Maximum (p=0.528) or True p=(0.942) Hallux Dorsiflexion between participants that tested positively and negatively for the HM test. HRPP was found to have a correlation with Maximum Hallux Dorsiflexion (p=0.012). A cut-off point of 1.67, used to distinguish positive and negative scores, was found for HRPP. Whilst HRPTI was not found to have any correlations, LRPP was found to have a correlation with Maximum Hallux Dorsiflexion (p=0.033). A cut-off point of 2.60 was found for LRPP. LRPTI was found to have a correlation with Maximum Hallux Dorsiflexion (p=0.03). A cut-off point of 1.68 was found for LRPTI. The combination of HM and HRPP was found to have the most significant difference between positive and negative groups for Maximum Hallux Dorsiflexion (p=0.014). Conclusion: The HM and NWB tests are not valid tests that represent hallux dorsiflexion during gait. With regards to plantar pressure analysis, greater the peak pressures under the hallux and lesser metatarsals compared to the first metatarsal head, correlated to decreased Maximum Hallux Dorsiflexion. Greater pressure time integrals under the lesser metatarsals compared to the first metatarsal head, correlated to less Maximum Hallux Dorsiflexion. The combination of HM and HRPP tests showed a more significant difference between positive and negative groups for Maximum Hallux Dorsiflexion. No significant differences were noted when using True first MPJ dorsiflexion between midstance and toe-off. Hence the author cautions other researchers to specify how first MPJ dorsiflexion was calculated. Description: M.SC.CLINICAL BIOMECHANICS 2019-01-01T00:00:00Z https://www.um.edu.mt/library/oar/handle/123456789/52987 Title: The effect of the transverse location of the subtalar joint axis on foot kinetics and kinematics Abstract: Background: Locating the subtalar joint axis (STJA) as per Kirby (1987), is a routine test used by clinicians during biomechanical assessment of patients. However, its validity in relation to peak plantar pressure (PPP), pressure time integral (PTI) and foot kinematics is poorly evidenced in literature. Aim: To investigate a possible relationship between the location of the STJA using the palpation technique as described by Kirby (1987) with foot kinetics, mainly PPP and PTI and foot multisegment kinematics. Methods: A non-experimental quantitative study, using a correlation research design and a deductive approach was employed in this research study. Twenty six healthy participants were recruited through convenience sampling and categorized into four groups according to the Foot Posture Index by an independent researcher. Participants were assessed for the location of the STJA using the palpation technique as described by Kirby (1987) and categorized into two groups ie. those having their STJA intersecting the longitudinal bisection of the foot (Group A), and those whose STJA did not intersect the longitudinal bisection of the foot (Group B). Foot kinetics, mainly PPP and PTI, were collected using a Tekscan HRMat™ and kinematic data using a 16 camera Vicon® Nexus Optoelectronic Motion Capture System through the Istituto Ortopedico Rizzoli multisegment foot model for both groups. Results: Participants with a medially deviated STJA exhibited a significant increase in PPP and PTI at the hallux (p=<0.0005), 2-5th metatarsal heads (p=0.032), medial calcaneus (p=0.001) and lateral calcaneus (p=0.004). Higher PPP values were also noted in the total forefoot area (p=0.018), and lateral midfoot area in Group B (p=0.029). As for kinematics, an increase in the total range of motion of the 1st metatarsal to ground motion was observed as the transverse location of the STJA was more medially deviated (p=0.024). Significant relationship was noted between the STJA angle and calcaneus to metatarsal foot segmental motion; where a significant increased dorsiflexion, increased inversion and decreased adduction motion was noted in individuals with a more medially deviated STJA. Moreover the calcaneus in relation to the shank was more adducted and remained longer in an everted position during stance phase in Group A. The forefoot was also more abducted in relation to the shank during stance phase in Group A than Group B. Conclusion: This research study has revealed that individuals with varying location of the STJA have distinct pattern of foot motion and kinetics. Moreover these results demonstrate that the foot is a flexible structure where movements can occur independently and adjust according to foot postural changes and adaptations generated during locomotion. These results are congruent with previous literature relating foot posture characteristics with foot kinetics and kinematics especially with regards to results relating forefoot kinetics; kinematics of calcaneus to metatarsal segment; 1st metatarsal to ground kinematics and shank to calcaneus kinematics. Description: M.SC.CLINICAL BIOMECHANICS 2019-01-01T00:00:00Z https://www.um.edu.mt/library/oar/handle/123456789/52986 Title: The effect of smoking on peripheral arterial perfusion in participants living with type 2 diabetes mellitus in Malta Abstract: Background: Peripheral arterial disease (PAD) is a systemic disease often referred to as a progressive atherosclerotic disease that impedes arterial perfusion to the lower extremities. It is strongly associated with cardiovascular and cerebrovascular ischaemic events affecting both the expectancy and quality of life. Although tobacco smoking and type 2 diabetes mellitus are two main risk factors of PAD, they are still highly prevalent in Malta. Aim: To investigate the effect of tobacco smoking on peripheral arterial perfusion in participants living with type 2 diabetes mellitus in Malta. Objectives: To compare and conclude whether there is a statistical significance in arterial perfusion of the lower limbs between smokers, past smokers and non smokers living with type 2 diabetes mellitus in Malta using validated non-invasive diagnostic tools available in the primary care setting. Design & Methods: A non-experimental quantitative research was utilised to investigate the effect of tobacco smoking on peripheral arterial perfusion in a cohort of 32 participants with type 2 diabetes mellitus; [Smokers (n=11), Past smokers (n=11) and Non smokers (n=10)]. Participants were aged ≥ 40 & ≤ 85 years old, not subject to any high-risk factor linked with PAD except for tobacco smoking, type 2 diabetes mellitus and controlled hyperlipidaemia. The 3 smoking categories were matched on age (years), body mass index (BMI, kg/m2), eGFR (estimated glomerular filtration rate, mL/min/1.73m2), packet years (packs of cigarettes smoked per day multiplied by the years of continued smoking), duration of diabetes mellitus (years) and HbA1c levels (glycated haemoglobin, %) utilising frequency distribution. PAD was clinically assessed utilising the Toe Brachial Pressure Index (TBPI) & a hand held Doppler as part of the Huntleigh® Dopplex Assist instrument. TBPI value of ≤0.7 was suggestive of PAD while >0.7 was considered normal. Results: One Way ANOVA test showed significant difference in the TBPI scores between current, past and non smokers living with type 2 diabetes mellitus (p<0.05) when combining both left and right limbs (n=64) due to insignificant difference between left and right TBPI means (p>0.05). Chi-Square test found no significant difference between Doppler waveforms and smoking status (p>0.05) in both left (n=32) and right (n=32) feet, however χ2 tests showed larger percentages of non smokers with triphasic and biphasic waveforms, larger percentages of current smokers with monophasic and biphasic waveforms and larger percentages of past smokers with monophasic waveforms. Conclusion: Results of this study are in line with the literature with a low TBPI score indicative of PAD. This study has highlighted the important effects of tobacco smoking on peripheral arterial perfusion in individuals living with type 2 diabetes mellitus while also shedding light on the importance of smoking cessation and early identification of PAD especially in asymptomatic subjects were the disease can progress unnoticeably leading to severe lower limb and cardiovascular implications. Description: B.SC.(HONS)PODIATRY 2019-01-01T00:00:00Z https://www.um.edu.mt/library/oar/handle/123456789/52984 Title: A reliability study of four validated diabetic foot ulcer classification systems Abstract: Background: One of the many complications of diabetes mellitus is foot ulceration. Diabetic foot ulceration may have different presentations depending on the pathogenic contributing factor and this may lead to various outcomes. The need to classify, score and describe these lesions is needed for various reasons including clinical documentation and reporting. An agreed classification and scoring system in routine clinical care can improve documentation and communication between health care professionals, which may also improve the ease of discussion regarding potential outcomes at an early stage. Several classification systems have been devised in an attempt to address these requirements. Having a high inter-rater agreement between these classification systems can facilitate the logical approach to treating as well as predicting the outcome of diabetic foot ulceration. Aim: The aim of the study was to determine the inter-rater reliability between four validated classification systems in the grading/scoring of diabetic foot ulceration. Research Design and Method: A prospective non-experimental comparative study was held at the diabetes foot clinic at Mater Dei hospital. Patients with diabetes presenting with a new ulcer or long-standing ulcer were enrolled in this comparative study. Each ulcer was graded/scored by three experienced clinicians using four-classification systems; namely the University of Texas system, the SINBAD system, the Meggitt-Wagner system and the PEDIS system. These classifications were evaluated with score sheets at hand consisting of a description of each category. Results: All four classification systems had a satisfactory inter-rater agreement (p<0.05) when evaluated by three raters of various clinical experience, however, the strength of the agreement varied between classifications. The Meggitt-Wagner system had an almost perfect agreement, the SINBAD and UT systems had a strong inter-rater agreement whilst the PEDIS had a moderate inter-rater agreement. Conclusion The more complex the classification, the weaker the inter-rater agreement. Until a gold standard is reached, these classifications should not be used a single tool to predict ulcer outcome or determine treatment options. Such classifications should only be used in combination with other routine clinical assessments, to acquire an overall prognosis and manage appropriately to achieve the best possible outcome. Description: B.SC.(HONS)PODIATRY 2019-01-01T00:00:00Z