Podiatry
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Item Manipulation of the foot in the treatment of patients with Morton’s neuroma(Queen Margaret University, Edinburgh, 2024-06-26) Cashley, DavidIntroduction Manipulative therapy’s rationale is pragmatically appealing as a non-invasive treatment for Morton’s neuroma (MN), involving targeted manipulations of relevant joints. Nevertheless, manipulation’s efficacy has received limited scrutiny. This thesis comprised four data-driven chapters offering novel investigations associated with manipulation as a treatment for MN. The latter included a critical appraisal of the clinimetric utility of pressure testing for discomfort thresholds (PTT) as a novel outcome in this context (n = 26; Chapter 5), an exploratory pragmatic controlled trial investigating Manipulation versus Steroid Injection in the treatment of patients with Morton’s neuroma focusing on self-reported pain levels (VAS) and PTT (n = 61; Chapter 6) and other PROMs reflecting functionality and health (Chapter 7). A final data chapter (Chapter 8) contributed secondary analyses of data in Chapters 6 and 7 exploring novel factors in enhanced clinical outcomes of non-surgical treatment of Morton’s neuroma using descriptive multivariate modelling and discriminant analysis. Method The thesis’s primary study (Chapters 6 and 7) featured an exploratory, pragmatic randomised controlled trial was designed to investigate the efficacy of an acute, short dosage (6, weekly episodes) of physiologically-principled manipulations, featuring discrete, high-velocity thrusting manoeuvres for treating Morton’s Neuroma. Adults electing treatment for Morton’s neuroma were randomly allocated to manipulative therapy (n = 29) or corticosteroid injection (n = 32). Baseline and follow-up (at 1·5, 3, 6, 9 and 12 months following treatment cessation) outcome measures of self-reported pain levels (VAS), pressure testing for discomfort thresholds (PTT) and functionality (walking and standing [MOxFQws], pain [MOxFQp)] and social interaction [MOxFQsi]; activities of daily living [FAAMdl], sports participation [FAAMspt] and general health [SF-36 PCS & MCS]) were measured ipsilaterally and by inventory. Results Chapters 6 and 7 showed that manipulation elicited substantive gains immediately after intervention (VAS [Cohen’s d, 3·3; 84·4%]; PTT [d, 2·3; 147·0%]; MOxFQws [d, 1·4; 52·8%]; MOxFQp [d, 1·3; 45·5%]; MOxFQsi [d, 0·9; 39·2%]) or accumulated during follow-up (FAAMdl [d, 2·2; 40·8%]; FAAMspt [d, 1·5; 66·1%]). Concomitant gains interactively for control participants were modest (d, 0·4 to 1·0; 16·6% to 45·9%) (p < 0·05 to p < 0·0005). Retention of improvements following manipulation cessation was substantial for all metrics, significantly better than baseline scores (VAS, PTT, MOxFQws, MOxFQp, MOxFQsi, FAAMdl, FAAMspt, SF-36 PCS and SF-36 MCS [d, 1·1 to 3·4; 40·8% to 152·3%]) and consistently exceeded that for corticosteroid injection (p < 0·01 to p < 0·001). Group mean intra-session and inter-day variability (V%) of PTT (Chapter 5) ranged between 6.8% and 13.6% for experienced and inexperienced test administrators, respectively, and suggested compromised precision amongst serial measurements of PTT over extended periods of time. Within Chapter 8, predictive multivariate modelling showed that in internal classification analyses, 88.9% of patients could be assigned correctly to high- and low-responders to treatment. Conclusion (i) Manipulation elicited significant and clinically relevant improvements and retention in self-reported levels of pain, discomfort and functionality for patients electing treatment for Morton’s neuroma; (ii) Exploratory multivariate modelling provided a significant prediction model for successful non-surgical treatment outcomes; (iii) Single measurements showed compromised precision amongst serial assessments of PTT.