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What do you make of the conclusion?

Interesting.
These are fairly small cohorts, but even so, I would have expected to see some difference between the two.
Not an easy study to undertake I would think , and like many research results, would seem to throw up more questions than answers .
Regards,
David

Interesting conclusion. Could save a few pounds on scalpel blades though I suppose

Alec.

Excellent, much needed piece of research. I'm off to the library to read the full article. Interesting to note those with callosities had more significant joint erosion scores. As far as sample size goes, Woodburn's work on foot orthoses and RA (I think it was published in late 2003) made use of power calculations to suggest appropriate sample size, so it's likely he'll have done the same here, but until I've read the article I can't really say.
Good stuff,
Bob

Dear Colleagues,
Apologies if this appears for the 2nd time as my first messagae didn't seem to make it! Craig Payne asked if I'd make a contribution to this thread so thank you for your interest in this work. If you are unable to access the paper then I can email a pdf copy.
I think Heidi Davys made a good attempt to evaluate a common intervention and be creative methodologically to introduce sham control. To cover some of the issues raised-
1. Sample size was determined from a power calculation based on a previous, unblinded preliminary study [1]. The effect size was large in the preliminary study so the sample needed for this RCT was relatively small. There are fundamental issues using VAS pain scores in sample size calculations and my colleagues in our outcome research group would frown heavily on this practice! We have a new and better outcome tool for RA foot for future RCT's.
2. Yes we were also surprised about the outcome. If you think you were going to see a positive outcome it would be for this type of intervention! The evidence suggests not and it reinforced for us the need to include sham/placebo control for all foot interventions, which are largely physical in nature.
3. The sham control was very important and it seemed to work, as patients not only reported improved symptoms (modest) but also walked faster. Heidi meticulously recorded patient comments during the study and it was very surprising to hear patients adamently state that they had their normal treatment when in fact they were in the sham group.
4. Non-specific behavioural issues heavily influenced these findings and in the future we intend to study new patients and use practitioners unfamiliar to the patients.
5. Why are these patients not sent for FF reconstruction? This question has been thrown at us and in many of these cases motivation for this is not high since most of the patients had received past surgery in the foot and other proximal joints. An economic analysis should also be included in the future to address this issue.
6. Patients seem to be benefitting from a treatment largely consisting placebo effect. Not surprising since the intervention has the features which magnifiy this (skin prep, surgical instruments, cutting, dressings etc).
7. Most important outcome of study for me? Placebo/sham control is essential when evaluating these types of interventions and this may require some interesting strategies in the study design.
Thanks for your interest in this work.
Jim Woodburn

[1] Woodburn J, Stableford Z, Helliwell PS. Preliminary investigation of debridement of plantar callosities in rheumatoid arthritis. Rheumatology 2000;39:652-654.

To All,
I had a great time in New Zealand last week.
Arrived back in Wollongong full patient load, thank goodness (pay for all the retail therapy).
Had a patient with RA so typical of the one's Dr Woodburn described in NZ, (ulceration clear exudate 2nd and 3rd met heads). I networked with her G.P. and he agreed that surgery was the one 1 priority. She is due to see her Professor at RNS Hospital (Sydney Australia) next week.
Follow up should be interesting.

Don Scott

To Don ESWT,
Just arrived back in the UK and also thoroughly enjoyed the Christchurch meeting. I think your plan of action is spot on. Now the callus sites are starting to ulcerate, like the diabetic foot, this will be the strongest predictor for future ulceration so a surgical opinion is warranted. Good luck and I'd be keen to know what the eventual outcome is.
Best wishes,
Jim Woodburn

Dr Woodburn,
I have a pre op cast of both feet in all their glory. I hope to report that my patient's case is rushed through for surgery via main stream medicine. Failing that maybe one of the Australian Podiatric Surgeons can help me advise my patient of a faster route.

On another point your 3D MRI was interesting. I am also involved with CT Light Speed 16. In less than 11 second over 1,000 images were taken, from the A/P and M/L views, a 3D image was reproduced. Within a few months a few months a new generation of software will be introduced (How can we keep up with the technology).

Radiology imaging is very important for the diagnosis of foot complaints. We have to lobby the Federal Government to allow Podiatrists more detailed imaging techniques. (eg Ultrasound, CT Scan and MRI)

Don Scott

Dr Woodburn,
Patient is now on short list if she wishes to accept

Don Scott