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Measuring and Managing Foot Muscle Weakness Submitted by Penelope Jane Latey in Fulfilment of the Requirements for the Degree Of

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Measuring and Managing Foot Muscle Weakness Submitted by Penelope Jane Latey in Fulfilment of the Requirements for the Degree Of MEASURING AND MANAGING FOOT MUSCLE WEAKNESS Penelope Jane Latey A thesis submitted in fulfilment of the requirement for the degree of Doctorate of Philosophy Faculty of Health Sciences The University of Sydney 2018 CANDIDATE’S CERTIFICATE I, Penelope Jane Latey, hereby declare that the work contained within this thesis is my own and has not been submitted to any other university or institution for any higher degree. I, Penelope Jane Latey, hereby declare that I was the principal researcher of all work contained in this thesis, including work published with multiple authors. I, Penelope Jane Latey, understand that if I am awarded a higher degree for my thesis titled Measuring and managing foot muscles weakness being submitted herewith for examination, the thesis will be lodged in the University Library and be will available immediately for use. I agree that the University Librarian (or in the case of the department, the Head of the Department) may supply a photocopy or microform of the thesis to an individual for research or study or to a library. Penelope Jane Latey 29th June 2018 i SUPERVISOR’S CERTIFICATE This is to certify that the thesis titled Measuring and managing foot muscle weakness submitted by Penelope Jane Latey in fulfilment of the requirements for the degree of Doctorate of Philosophy is in a form ready for examination. Professor Joshua Burns The University of Sydney and Sydney Children’s Hospitals Network 19th June 2018 ii ACKNOWLEDGEMENTS I would like to begin my acknowledgements with mention of my family, particularly my children, Frederick and Camilla for reminding me of what really matters. To my friend Sylvia for her on going encouragement and Brian whose patience and reassurance was unwavering. The work presented in this thesis would not have been possible without the support and encouragement from many brilliant people in my life. Firstly to my primary supervisor Professor Joshua Burns, thank you for your guidance, clarity of thought and timely advice throughout my candidature. Your astute questions has made my PhD journey an immensely rewarding experience. To my co-supervisors Dr Claire Hiller, Dr Jean Nightingale and Dr Marnee McKay, thank you all for believing in me and encouraging me to be the best I can be. Thanks to Dr Jill Clarke, for sharing her remarkable ultrasound skills. To John Eisenhuth for the provision of his extensive electrical engineering, building and coding skills. Librarians, Kanchana Ekanayake and Elaine Tam for their patience and help. A very special thank you to the incredibly passionate staff and students of the Musculoskeletal Health Research Group for their willingness to share their knowledge. I would also like to thank the staff and clients of my studio, Modern Pilates and my extended work family around the world, for their interest and encouragement during this process. I feel very privileged to have shared this time learning with you all. iii DEDICATION This thesis is dedicated to those that are no longer in this world, though of this world: my parents Heather and Fred Schubach, a special companion Craig Johnston and friend Narelle Smith. Intelligence is something we are familiar with, an old book, an old friend. But what is wisdom? If intelligence is the ability to speak, wisdom is the capacity to listen. If intelligence is the ability to see, wisdom is the capacity to see far. If intelligence is an eye, wisdom is a telescope. ……. To see ……. beyond the first dimension or context; of time and space and being. Wisdom in other words, is perspective. (Wrangham and Peterson 1997) iv ABSTRACT Foot problems with accompanying foot pain are highly prevalent, affecting 24% of the population at any given time. Foot pain is associated with intrinsic foot muscle weakness and reduced toe flexor strength. Foot muscle weakness is caused by disease, injury, inactivity and ageing, with disabling functional consequences. Measuring and managing intrinsic and extrinsic foot muscle weakness can be challenging. Exercise is known to improve muscle weakness, however ensuring participant engagement and adherence to the correct technique is often difficult to achieve. Biofeedback may improve both accuracy in performance and adherence. The purpose of this thesis is to determine the level of association between foot muscle weakness and pain, develop a safe biofeedback foot exercise device and evaluate its feasibility to guide performance of exercise skill and adherence. Chapter One of this PhD thesis describes the intrinsic foot muscles and critically reviews the available literature on foot muscle measurements. The causes and consequences of foot muscle weakness, various foot exercises, limitations to performance skill and adherence are appraised. The results of a systematic review on the relationship between foot pain, muscle strength and size are presented in Chapter Two. Eight studies were identified evaluating the relationship between foot pain and foot muscle strength (n=6 studies) or size (n=2 studies). There was evidence of a significant association between foot pain and muscle weakness when pain is of high intensity, and weakness measured by toe flexion force. Chapter Three presents a reproducibility study assessing the size of abductor hallucis and the medial belly of flexor hallucis brevis muscles by ultrasound in 21 participants aged 26-64 years, and identified their relationship with toe strength, foot morphology and balance. Intra-rater reliability was excellent for both the abductor hallucis (ICC3,1 = 0.97, 95%CI 0.94 to 0.99) and medial belly v of flexor hallucis brevis (ICC3,1 = 0.96, 95%CI 0.96 to 0.98). Significant associations were identified between cross-sectional area of abductor hallucis and great toe flexion force measured by pedobarography (r=0.623, p=0.003), foot morphology measured by arch height in sitting and standing, foot length and truncated foot length (r=0.597, p=0.004 to r=0.580, p=0.006), balance measured by the maximal step length test (r=0.443, p=0.044). A significant association was also identified between cross-sectional area of the medial belly of flexor hallucis brevis and foot morphology measured by the Foot Posture Index, foot length and truncated foot length (r=0.544, p=0.011 to r=0.451, p=0.040). After controlling for physical body size, cross-sectional area of abductor hallucis remained a significant correlate of great toe flexor strength (r=0.562, p=0.012). Chapter Four describes the development and construction of the ‘Archie’ biofeedback medical device. This process included the redesign and build of the housing, a significant upgrade to Archie’s safety features, new electronic circuitry and substantially improved visual feedback. The feasibility of the Archie biofeedback device is evaluated in Chapter Five by repeat testing with 30 healthy adults (aged 23-68 years) performing four types of foot exercises using Archie to guide arch movement and foot placement. All participants performed the foot exercises on Archie alone (to measure consistency) and with biofeedback (to measure device effectiveness). Seventeen of 19 (89%) arch movement and foot location variables were collected consistently with Archie during the foot exercises. Archie with biofeedback significantly improved foot location adherence for all exercises (p=0<009). Twenty-nine of 30 (97%) participants reported that Archie with biofeedback helped correctly perform the exercises. Archie appears to be a safe, feasible biofeedback system to assist participants with performing foot exercises and improve adherence using the correct technique. Archie merits further research to explore the longitudinal benefits in community-based clinical trials to treat foot muscle weakness. vi TABLE OF CONTENTS Candidate’s Certificate................................................................................................................ i Supervisor’s Certificate ............................................................................................................. ii Acknowledgements ................................................................................................................... iii Dedication ................................................................................................................................. iv Abstract ...................................................................................................................................... v Table of Contents ..................................................................................................................... vii List of Figures .......................................................................................................................... xii List of Tables ........................................................................................................................... xv Outline of the thesis ................................................................................................................ xvi Dissemination of Research ................................................................................................... xviii CHAPTER ONE: 1. Background to thesis............................................................................................................ 1 1.1 Overview of the intrinsic foot muscles ................................................................................ 4 1.1.1 Anatomical variations ................................................................................................... 7 1.1.2 Medial muscles of
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