In this exploratory data analysis, neither the type of course nor the age or sex of participants had a significant impact on their assessment of whether the MFS course was worthwhile. This, combined with the consistently high level of participant satisfaction, supports the assumption that the approach of empowerment by conveying theoretical knowledge and exercises that can be performed autonomously, is beneficial for the majority of participants regardless of the magnitude of their pre-existing problem, the type of course attended, or participants’ age or sex.
The composition of the surveyed group was very inhomogeneous in terms of sex, age, and the type of course attended. This phenomenon has been addressed previously in the literature (11, 12, 19). According to results of the Robert Koch Institute (RKI)’s "Adult health status study in Germany,” women use these types of services almost twice as often as men (19).
The fact that the compact course was more favored (88%) than the classical course was surprising. Only the classical course was recognized as a preventive service, according to the German Social Security code (§ 20 Abs. 4 Nr. 1 SGB V), and its cost is covered by health insurance companies. Additionally, some respondents stated that the classical course made more sense from a pedagogical point of view. The popularity of the compact course may be caused by the fact that mainly working people participated in the course (median age: 55 years) and many participants had to travel far to attend the course.
In the above-mentioned study by the RKI, which addressed group composition in prevention courses, most participants were in the 65‒79-year age group (19). In contrast, the average age of the MFS participants was lower, at around 55 years. One possible explanation is that many prevention groups are concerned with cardiovascular diseases, which often emerge at a later age than common foot problems. For example, hallux valgus usually first occurs between the ages of 30 and 60 years (20).
Only half of the participants (56.5%) consulted a specialist because of their foot problem. Hence, it would be interesting to know whether the remaining 38.8% of respondents who had at least slight problems or a foot malalignment had used the MFS as primary care or had previously seen a general practitioner. Unfortunately, the questionnaire did not address this issue; in future studies, the questionnaire should be amended to include questions addressing this item.
The insoles, used by one-third of the participants, were not specialist prescribed. Excessive care or improper selection of insoles can result in deconditioning of the active, muscular foot support, and in the worst case, can actually cause foot problems. To improve this situation, the MFS now aims to expand cooperation with general practitioners, so that potentially interested people can be assisted earlier. Additionally, the transfer of knowledge about insoles will be optimized.
All three of the most frequently stated reasons for course participation implied that participants had at least a slight problem with their feet. Hence, we conclude that participation, solely for preventive reasons, is rather rare.
The course format was rated very positively; only a small number was unsatisfied with the extent of the course (5.2%). This may be related to the choice offered. It is possible for everyone to choose the model that best suits personalized needs. Despite the much higher popularity of the compact course, it would make sense to continue offering the classic course in future, as it is pedagogically more valuable. In addition, the phases of self-exercise between the lessons, which are not available in the compact-course, are an integral part of the classic course. Future research may address this potential difference between the course types using a prospective, function-related quality of life assessment.
Opinions regarding the informative content of the courses were predominantly positive. It is particularly noteworthy that even those who had participated in 2015 rated this aspect of the course positively. This speaks to the almost surprisingly good sustainability of the imparted knowledge, particularly in relation to the effort required.
The assumption that those who had a more severe foot problem prior to the course may also feel more stress during the course was not confirmed by the results.
The respondents' desire for further course dates (7.7%) should be considered critically, as most of the participants consciously opted for a compact course and thus for a single appointment. Therefore, it is uncertain how many would participate in future events. Nevertheless, a refresher course should be offered. Another means of better preserving the MFS effects could be the introduction of an online or app-based intervention.
The most frequently posed criticism (2.4%) that there was not enough time to discuss individual problems, is understandable. Owing to the time constraint, a more personalized treatment could not be offered. Moreover, an extension of the course is contrary to its concept. Consequently, an extended concept of foot treatment with individual orthopedic examination and individual treatment options, besides the MFS course, would require incorporation.
The first question of the effects-block of the questionnaire related to whether, at the time of the survey, respondents still felt that they had knowledge about the function of the foot and were familiar with the exercises that support the statics and function of the foot. The result was almost unexpectedly positive, even though assessment of one's knowledge decreases with growing time distance. Nevertheless, the overwhelmingly positive answers to this question suggest that the type of theoretical content, type of exercises, etc., are well suited to achieving patients’ satisfaction in perception of their empowerment within a short time frame of 6‒8 h. However, the evaluation could not clarify whether the course had actually motivated participants to correct their foot position actively or changing their foot's function in everyday life. To this end, prospective objective studies are required.
Improvement in awareness and perception of the feet through the MFS course was also positively rated. Refined perception did not decline as much with increasing time-distance. This might suggest that the abstract ability of improved perception, once enhanced, fades less over time than specific knowledge, as addressed above.
As knowledge fades over time, the frequency of performance of the exercises learnt in the course decreased with increasing time-distance. Nevertheless, about one-third of those who had attended a course in 2015 still performed exercises regularly. Based on the large number of people who performed exercises, even after a long time, it can be deduced that the course is motivating and the Spiraldynamik® exercises, which focus on empowerment, provide enough benefit to result in lasting application by the participants. As described above, the physiological function of the foot is complex, but the time available in the course seems to be sufficient to convey an understanding of the function and in learning the exercises. However, we did not test whether the participants were actually able to perform the exercises correctly at the time of the evaluation.
The question posed by the second block aimed to ascertain whether participation had influenced the way the feet are used and treated. The collected answers show that the MFS also extends to factors that come into play in everyday life, such as daily use and care.
When contemplating the question how the course has impacted foot complaints, the phenomenon that the effects reduced slightly over time. Although the assessments of participants from the 2015 course were still surprisingly positive, they more often had the opinion that the course had a negative impact or no effect, compared to responses of participants from other years. With regard to this question, the comparison between preventive and curative intention group showed that the former was assessed more positively. This was surprising, because satisfaction, as examined by the statement, “Attending the foot-school was worthwhile for me,” was already very high and without significant differences between curative and preventive group. In addition to the pure alleviation of complaints, which is queried here, this could indicate that other factors also play a role in the evaluation. Some of those factors may include newly gained knowledge about the anatomy and function of the foot, greater understanding of one's problem or new insights into different treatment options.
When comparing the use of insoles before and after the course, a higher proportion of people were found using insoles after participating in the course than before joining. This finding is somewhat surprising, since the concept of the MFS, while not attempting to replace insoles, focused on making some insole use obsolete by training the active support of the foot architecture.
Nevertheless, the selection of footwear was clearly improved by the course. Thus, almost a quarter of those surveyed stated that they now paid more attention to the feet-shoe compatibility factor. This is particularly substantial because according to their own statement 63.1% had already done that before participation.
With the exception of a few rare cases, such as those where surgery was unavoidable (2,8 %), the reported complaints developed positively after course participation as compared to before (median before: 5, after: 3). From this it may be concluded that functional foot problems can be treated satisfactorily conservatively in the overwhelming number of cases and that MFS can be a useful element. However, pain is a multifactorial process, and without a randomized controlled study, the reduction in pain cannot be attributed solely to the MFS.
The limitations of the study were its retrospective, monocentric, internally evaluated attributes based on PROs. Furthermore, recall and response bias, both of which are typical for retrospective surveys, may have potentially affected the results. The questionnaire, which was designed specifically for our study and was not validated, may have influenced the external validity of the results. Validation should be considered for future research. An extended evaluation, using a prospective, randomized, and controlled design with objective and function-related parameters should be used to explore the effects of the course further in future.
 German institute with the aim to research and prevent infectious diseases, which also has the task of monitoring health nationwide