Explanatory model for diabetic foot ulcers


First paper from the collaborative work between Dr Zulfiqarali G. Abbas and colleagues from the Muhimbili University of Health and Allied Sciences and Abbas Medical Centre in Dar es Salaam, Tanzania  and Professor Nachi Chockalingam and colleagues at Staffordshire University has just been published in the Journal of Diabetes and its Complications.

This particular work is part of a wide ranging research focusing on Diabetic foot and its complications and is led by Professor Roozbeh Naemi at Staffordshire. This research was aimed at identifying various parameters that will help explaining the presence of foot ulceration in patients with diabetes.

The work examined the biomechanical, neurological, and vascular parameters along with other demographics and life style risk factors that could explain the presence of foot ulcer in 1270 patients with diabetes. Although the data focused on patients in Tanzania, the results has  a global implication. 

The results of this study showed that the participants with ulcerated foot exhibit distinct characteristics in some of the foot related clinical observations. Swollen foot, limited ankle mobility, and peripheral sensory neuropathy were significant characteristics of patients with diabetic foot ulcer. In addition, the explanatory model outlined within this research clearly shows that only one out of three patients with ulcerated foot showed common characteristics that are typically considered as contributing factor to ulceration.


Can a combination of lifestyle and clinical characteristics explain the presence of foot ulcer in patients with diabetes?
Available Online 01 March 2019
Roozbeh Naemi, Nachiappan Chockalingam, Janet K. Lutale, Zulfiqarali G. Abbas

Congratulations – Nicky !

Nicola Eddison, one of the senior orthotists in the UK who recently completed her Ph.D at the Centre for Biomechanics and Rehabilitation Technologies writes on her experience:

I have worked in the NHS as the clinical lead for orthotics at the Royal Wolverhampton NHS Trust, for over a decade. My passion is paediatric orthotics, primarily the provision of ankle foot orthoses – footwear combinations (AFO-FCs) for children with neurological conditions.

I chose to undertake a Ph.D to increase my understanding of the biomechanics involved in AFO prescriptions and to investigate the effects of AFO optimisation (commonly termed AFO tuning) in an attempt to improve clinical outcomes and better inform the wider clinical community.

My research focused on the effect of biomechanically optimised AFO-FCs on the gait of children with cerebral palsy.

This research is first of its kind, to offer data in a case series analysis format on AFO-FC tuning, providing individual data rather than group means. For a practising clinician this is very important as each patient is different. I hope others will follow this model. In addition, my work is also the first piece of research which looked at the effects of AFO-FC tuning on energy expenditure and patient perception.

The project provides quantitative data to support the importance of biomechanically optimising AFO-FCs and as such, it contributes to the improvement of AFO prescriptions for children with cerebral palsy.

I thoroughly enjoyed conducting this research and have applied my research knowledge to practice. I intend to continue working with Professor Chockalingam and Dr Healy to help tackle issues relating to Orthotics and Assistive Technology.

As Nachi says, “research is addictive” and I want to continue to work on clinically relevant research questions which will have a substantial impact on people’s lives.

Publications from Nicky’s work:

Eddison N and Chockalingam N (2012): The effect of tuning ankle foot orthoses-footwear combination on the gait parameters of children with cerebral palsy. Prosthet Orthot Int published online 24. July 2012. https://doi.org/10.1177/0309364612450706

Eddison N and Chockalingam N (2014): Ankle foot orthosis- footwear combination tuning: An investigation into common clinical practice in the United Kingdom. Published online before print February 24, 2014 Prosthet Othot Int February 24, 2014. https://doi.org/10.1177/0309364613516486

Eddison N and Chockalingam N (2014): Response: Turning of rigid ankle-foot orthoses is essential. Prosthet Orthot Int, first published on April 1, 2014. https://doi.org/10.1177/0309364614525734

Eddison N, Mulholland M and Chockalingam N. Do research papers provide enough information on design and material used in Ankle Foot Orthoses (AFO) for children with cerebral palsy (CP)? : A systematic review. Journal of Children’s Orthopaedics, 2017; 1-9. https://doi.org/10.1302/1863-2548.11.160256

Eddison N, Healy A, Needham R and Chockalingam N. Shank – to – Vertical – Angle in AFOs: A comparison of static and dynamic assessment in a series of cases. Journal of Prosthetics and Orthotics . JPO Journal of Prosthetics and Orthotics · August 2017. doi: 10.1097/JPO.0000000000000141

Eddison N, Healy A, Needham R and Chockalingam N: Exploratory investigation into energy expenditure using tuned versus non-tuned ankle foot orthoses- footwear combinations in children with cerebral palsy. JPO Journal of Prosthetics and Orthotics. 2018. In Press.

Effectiveness and Cost-effectiveness of Prosthetic and Orthotic Interventions

An Infographic on the Effectiveness and Cost-Effectiveness of Prosthetic and Orthotic Interventions

The International Society for Prosthetics and Orthotics (ISPO) in partnership with the WHO, and funded by the United States Agency for International Development (USAID), recently published Standards for Prosthetics and Orthotics Service Provision. These Standards were developed to encourage better access to prosthetics and orthotics services.

To support the development of these Standards we were commissioned by the ISPO, in partnership with WHO and USAID, to conduct a systematic review.

What was the context to the project?

It has been estimated that in excess of 100 million people across the world are in need of a prosthesis or orthosis. However, it is projected that only 1 in 10 people in need has access to prosthetic and orthotic devices. To date no one has completed an overall examination of research examining orthotic and prosthetic interventions across healthcare.

What was the aim of the project?

The aim of this project was to complete a systematic review of the research to date which has examined the effectiveness of prosthetic and orthotic interventions.

How was information gathered?

Searches across 14 databases were used to capture all research in this area.

What were the main findings?

A large volume of research has been conducted in this area, however, there was limited high quality prospective studies. 319 English language randomised controlled trials were identified with only 4 of these examining prosthetic interventions, the rest examined orthotic interventions.

At present, for prosthetic and orthotic interventions, the scientific literature does not provide sufficient high-quality research to allow strong conclusions on their effectiveness and cost-effectiveness.

Key statistics

  • The database searches resulted in a total of 28,958 articles.
  • 346 randomised controlled trials were identified, of which 323 were English language. Of the 323 English language RCTs, 319 examined orthotic interventions and 4 examined prosthetic interventions.
  • Orthotic interventions were categorised by the medical condition/injury with 68 categorises identified.
  • The most studies conditions were:
  • Osteoarthritis (30 studies)
  • Fractures (26)
  • Stroke (22)
  • Carpal tunnel syndrome (20)
  • Plantar fasciitis (18)
  • Anterior cruciate ligament (post-surgery) (16)
  • Diabetic foot (15)
  • Rheumatoid and juvenile idiopathic arthritis (13)
  • Ankle sprain (10)
  • Cerebral Palsy, Lateral Epicondylitis, Low back pain (8 studies each)

What are the implications of the findings?

This review highlighted the vast range of outcome measures utilised with few studies reporting on the same outcome measures. It was also evident that studies in general did not assess if the prosthetic or orthotic interventions allowed the users to participate in the activities of daily living in which they wished to perform, which is the major consideration for the user. There are many methodological issues within this area of research which need to be addressed to strengthen the quality of future research, which would then allow conclusive decisions to be made on the effectiveness and cost-effectiveness of these interventions.

Link to full article:

Healy A, Farmer S, Pandyan A, Chockalingam N (2018) A systematic review of randomised controlled trials assessing effectiveness of prosthetic and orthotic interventions. PLoS ONE 13(3): e0192094. https://doi.org/10.1371/journal.pone.0192094


This work was supported by the International Society for Prosthetics and Orthotics (ISPO) (Sub-grant from ISPO’s Collaborative Agreement with USAID Rehabilitation of physically disabled people in developing countries – USAID cooperative agreement DFD-A-00-08-00309-00).

Mater Dei to the Grand Harbour; an Erasmus journey by JJ English

An Experience of Erasmus in Malta 

The opportunity to go to Malta to complete the data collection for my dissertation came at just the right time, and my time in Malta has proved to be a wonderful experience. There are a number of reasons why it was wonderful, and of course, one of the reasons was the sunshine; when I left Gatwick, there was still plenty of snow around, courtesy of the Beast from the East, and when I arrived in Malta, it was almost 20 degrees warmer.

I arrived on a Saturday night, and made use of the famous bus network to arrive at my destination. This was, for reasons of financial prudence, the University residence in the centre of the island, in the village of Lija. However, although being budget accommodation for students, it did have one particular feature which turned out to be particularly enjoyable; the swimming pool. And from the point of view of a mature student, it was nice to find that there were many other mature students residing there. The residence’s pool is shown below, and shows a typical day; despite the odd day of rain, in my 11weeks on the island, most days looked like this:

The pool was the perfect place to hang out with the diverse range of people studying in Malta; because the site also housed the main language school on the island, I was fortunate in being able to meet people from all over the world. In the course of the 3 months there, I spent time with people from China, Luxembourg, Japan, Finland, South Korea, France, Egypt, Italy, Canada, Spain, the US, Belgium, Columbia, India, Australia, and many other places besides. It may in fact, have been the most international experience of my life, which speaks volumes for Malta’s status as an international hub.

The university campus adjoins the Mater Dei hospital, and was where I was to meet my professor, whose PHd student I was also there to assist. Prof Grima is an enthusiastic practitioner of rowing, and in particular, of the distinctive style of rowing practiced in Malta, whereby four men in a boat propel the craft using two completely different styles; while two of the men row in the normal fashion, the other two stand up, and use the Venetian ‘gondola’ style of propulsion. It was the task of his PHD student to capture the 3-dimensional biomechanics of these Maltese rowers in the motion analysis laboratory, which was run by the podiatrists and physiotherapists of the Mater Dei hospital.

We soon strolled up to the hospital to meet Dr Alfred Gatt & Dr Cynthia Formosa, along with their podiatry colleague Matthew Schembri, who also happens to be an elite racing kayaker. This was an enormously fortunate coincidence for me, as I was in need of recruiting experienced kayakers who could come to a motion analysis laboratory. As it turned out, I couldn’t have come to a better place for the purposes of my study. Through the initial contact details provided by Mr Schembri, I was able to speak to a diverse range of kayakers; not only racing kayakers, but also polo kayakers, and sea kayakers. In addition to this fortunate situation, I discovered that there was something especially generous about the Maltese kayaking community, who all lent me so much support, not only for my data collection, but also in teaching me about the wider context of the kayaking world.

This kindness extended far beyond the efforts made to actually keep appointments in the laboratory. The coach for the Maltese kayaking racers, a former Olympian, was also kind enough to give me a lesson out between the yachts in Msida creek, just to the north of Valetta. This made me realise what a very different experience race kayaking is from the kayaking I’d known in the UK.

In addition, 4 of the 9 volunteers were also very experienced sea kayakers, with at least two of them having kayaked from Tunisia to Malta, and from Malta to Rome. To my great surprise and joy, they invited me to go sea kayaking with them on a particularly glorious day, where I was given the precious and rare opportunity to use not only modern paddles, but also Aleut & Greenland Eskimo paddles; something I hadn’t expected to happen, and particularly useful in that I was hoping to relate the captured kayaking biomechanics to phenomena seen in Eskimo archaeology, and which is thought to follow on from long hours of traditional kayaking. Having discussed the problems of towing whale and walrus carcasses for many miles, and the implications of this for Eskimo spinal mechanics, my kayaking colleagues were kind enough to let me tow them around the Grand Harbour, as the photograph below shows! (note the use of the Aleut paddle; something I would have struggled to find if I hadn’t lucked out in meeting the Maltese kayaking community; also note how blue the sea and the sky is; what a terrific day!).

This was one of the nicest days of the whole trip, as we kayaked from the Marsamxhett harbour to the north of Valetta, around the heavily fortified promontory at the end of Valetta, protected by St Elmo’s Fort, into the Grand Harbour to the south of Valetta. After a couple of hours, kayaking around enormous ships, and through a cave, we returned to Marsamxhett harbour, and surfed the waves back to the Sliema ferry terminal on the south side of Valetta, just to the right of centre of the picture below.

Perhaps no picture illustrates how pleasant an experience I had in Malta more than the picture my kayaking friends took of me that day;

In summary, I had one of the most interesting academic experiences of my life, and also, one of the most interesting extra-curricular experiences too, of the kind that only Malta would have been able to provide.

On the academic side, and in addition to the staff already mentioned, another colleague, Mr Darren Sillato, a physiotherapist with great expertise in running the laboratory, made himself available for support and advice at a moment’s notice, over the period of weeks. At the same time, everybody was happy to let me practice using the laboratory for the 3 week preparation period leading up to my data collection. To have such long-term and unlimited access to this technology was a priceless learning opportunity. It was also exceedingly helpful that the man who made all this possible, Professor Chockalingam, was also available during a visit to Malta, where he delivered a timely and useful overview of how to analyse the data that such laboratories can capture.

On the extra-curricular side, I was pleasantly surprised to find that even as a mature student, I was able to enjoy student life in much the same way as I did when younger, and the Erasmus experience has been a healthy reminder to me that university isn’t entirely about work, even for mature students; it can be a place where people can have fun getting to know each other too. As a result, I have taken away from Malta some of the fondest memories of my life, and remain eternally grateful to all the friends who helped make my time in Malta so enjoyable, in both spheres of experience.

Life as a PhD student: An Indian Experience by Stylianos Fanourakis

This is my very first blog and I would like to share a small part of my experience in India as a PhD student so far. I have observed a lot of similarities and obvious influences of western civilization on Indian lifestyle. It has been a month since I arrived in Tamil Nadu, which is located in the South of India. It is a unique place with its own distinctive language called Tamil in addition to the national language (Hindi). I have visited a few cities in Tamil Nadu and the major temples in those cities that are at least 2000 years old. It fascinates me to know that they remain intact even after the known history of wars, without any intention of the invaders to attack or destroy some of them. Those temples are also protected by UNESCO heritage committee and are indeed amazing.

India has a very interesting landscape, which is rich in flora and fauna. As an European, it is very interesting for me to see monkeys jumping around the place like stray animals. Personally, I have seen monkeys only in cages at the zoo but never at my doorstep like in here.

Indian food is tasty. However, it is difficult for me to adapt to a vegetarian lifestyle. Of course, there are options for non-vegetarians like me, but not so widely available in the place where I am staying.

I am currently at SASTRA university, where I have been invited to collaborate for several months during my PhD. I am impressed by the size of the campus, which is vivid with a lot of students. This may be due to the fact that I am used to divided campuses. In the UK and Greece, I have never seen a whole campus operating as a single entity. The campus is always alive and active with people working six days a week. Also, I found that unlike most countries, people in India including academic staff and students, work six days a week. However, I deem that human body requires more than just one day per week to rest and alleviate stress.

My project at SASTRA university is about developing an innovative device, like a fully automated weight-bearing ultrasound scanning machine. It is a complicated task and challenging to deal with , however, this fact makes it interesting. Absolutely, it will not be a common topic of research for a PhD program. I am working with two other PhD scholars from SASTRA university, Hari and Saru. Each one of us, have our own objective in order to achieve the ultimate goal, which is to construct a new fully automated weight-bearing ultrasound device.

My objective is to create a new approach to automated elastography by calculating a map of stiffness through the deformation of a stand-off material. The device will also include features such as automated segmentation of various types of tissues; independent of their mechanical properties or thickness. Finally, the ultrasound device will be able to identify if the sample tissue is healthy or pathologic by quantifying the homogeneity of textured features. Furthermore, the weight-bearing device is aimed to be implemented in everyday clinical practice. In summary, the project is expected to have beneficial outcomes and promising results.

From my experience, I can say that India has a lot of opportunities and prospects as a competitor to the global market. The cost of living in India is cheaper in comparison to many other countries; but, that does not mean the lack of quality. The current rate of renewals or updates in relation to the infrastructure and transportation are low. I would recommend that the public transportation services are improved and updated periodically. Also, eco-friendly vehicles with less air and noise pollution would be useful. Better waste management and recycling methods must be promoted. Additionally, implementing strategies that utilize the renewable energy sources like the solar panels, which takes advantage of the sunlight available throughout the year can be beneficial. Last but not the least, there is a need for investing more into health, safety and hygiene. If the above actions are taken, perhaps, India may soon be one of the upcoming powerful global players.