The use of 'off-the-shelf' foot orthoses in the reduction of foot symptoms in patients with early rheumatoid arthritis

A clinical practice guideline for the management of the foot and ankle in rheumatoid arthritis

Rheumatoid arthritis causes progressive joint destruction in the long term, causing a deterioration of the foot and ankle. A clinical practice guideline has been created with the main objective of providing recommendations in the field of podiatry for the conservative management of rheumatoid arthritis. Thus, healthcare professionals involved in foot care of adults with rheumatoid arthritis will be able to follow practical recommendations. A clinical practice guideline was created including a group of experts (podiatrists, rheumatologists, nurses, an orthopaedic surgeon, a physiotherapist, an occupational therapist and patient with rheumatoid arthritis). Methodological experts using GRADE were tasked with systematically reviewing the available scientific evidence and developing the information which serves as a basis for the expert group to make recommendations. Key findings include the efficacy of chiropody in alleviating hyperkeratotic lesions and improving short-term pain and functionality. Notably, custom and standardized foot orthoses demonstrated significant benefits in reducing foot pain, enhancing physical function, and improving life quality. Therapeutic footwear was identified as crucial for pain reduction and mobility improvement, emphasizing the necessity for custom-made options tailored to individual patient needs. Surgical interventions were recommended for cases which were non-responsive to conservative treatments, aimed at preserving foot functionality and reducing pain. Moreover, self-care strategies and education were underscored as essential components for promoting patient independence and health maintenance. A series of recommendations have been created which will help professionals and patients to manage podiatric pathologies derived from rheumatoid arthritis.

Developing a core outcome set for foot and ankle disorders in rheumatic and musculoskeletal diseases: A scoping review and report from the OMERACT 2022 foot and ankle special interest group session

OBJECTIVES

Foot and ankle involvement is common in rheumatic and musculoskeletal diseases, yet high-quality evidence assessing the effectiveness of treatments for these disorders is lacking. The Outcome Measures in Rheumatology (OMERACT) Foot and Ankle Working Group is developing a core outcome set for use in clinical trials and longitudinal observational studies in this area.

METHODS

A scoping review was performed to identify outcome domains in the existing literature. Clinical trials and observational studies comparing pharmacological, conservative or surgical interventions involving adult participants with any foot or ankle disorder in the following rheumatic and musculoskeletal diseases (RMDs) were eligible for inclusion: rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthropathies, crystal arthropathies and connective tissue diseases. Outcome domains were categorised according to the OMERACT Filter 2.1.

RESULTS

Outcome domains were extracted from 150 eligible studies. Most studies included participants with foot/ankle OA (63% of studies) or foot/ankle involvement in RA (29% of studies). Foot/ankle pain was the outcome domain most commonly measured (78% of studies), being the most frequently specified outcome domain across all RMDs. There was considerable heterogeneity in the other outcome domains measured, across core areas of manifestations (signs, symptoms, biomarkers), life impact, and societal/resource use. The group's progress to date, including findings from the scoping review, was presented and discussed during a virtual OMERACT Special Interest Group (SIG) in October 2022. During this meeting, feedback was sought amongst delegates regarding the scope of the core outcome set, and feedback was received on the next steps of the project, including focus group and Delphi methods.

CONCLUSION

Findings from the scoping review and feedback from the SIG will contribute to the development of a core outcome set for foot and ankle disorders in RMDs. The next steps are to determine which outcome domains are important to patients, followed by a Delphi exercise with key stakeholders to prioritise outcome domains.

The Management of Metatarsalgia in Rheumatoid Arthritis Using Simple Insoles: An Effective Concurrent Treatment to Drug Therapy

BACKGROUND

Metatarsalgia is a common affliction in rheumatoid arthritis (RA), often requiring aggressive pharmacologic treatment that carries associated adverse effects. The aim of this study was to investigate whether simple insoles would have a beneficial effect on forefoot pain, disability, and functional limitation in participants with RA experiencing forefoot pain.

METHOD

A prospective, quasi-experimental, pretest-posttest trial was performed at a rheumatology outpatient clinic. Participants were supplied with a simple insole comprising a valgus pad and a plantar metatarsal pad and covered with a cushioning material. The Foot Function Index (FFI) was self-administered before and 3 months after insole use.

RESULTS

Reductions in forefoot pain (from 56.78 to 42.97) and total (from 41.64 to 33.54) FFI scores were noted. Statistical significance for this reduction was achieved following the t test (P = .002 and P = .0085, respectively). However, although reductions in mean disability and activity limitation scores were recorded (from 50 to 44.85 and from 18 to 14.57, respectively), these did not reach significance (P = .151 and P = .092, respectively) Conclusions: Simple insoles have been shown to be effective in reducing total and forefoot pain FFI scores in patients with RA experiencing metatarsalgia. This treatment offers advantages because these devices can be fabricated simply and cheaply, thus initiating the patient on an effective orthosis therapy immediately in the clinic without having to wait for prolonged periods until custom orthotic devices can be supplied.

Physical Examination Tool for Swollen and Tender Lower Limb Joints in Juvenile Idiopathic Arthritis: A Pilot Diagnostic Accuracy Study

BACKGROUND

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children, with lower limb involvement highly prevalent. Recent evidence has highlighted the lack of specific lower limb physical examination (PE) tools for clinicians assisting the paediatric rheumatology team in identifying lower extremity disease in patients with JIA. Early clinical detection may lead to more prompt and targeted interventions to reduce lower limb problems in children with JIA. The aim of this pilot study is to provide preliminary data on the diagnostic accuracy of a lower limb PE tool in JIA.

METHODS

Children with JIA requiring magnetic resonance imaging (MRI) on their lower limb joints per their usual care were eligible. Lower limb joint counts were conducted clinically by a podiatrist and paediatric rheumatologist using the proposed twenty joint per side, PE tool. The PE were compared to MRI assessments completed by two independent paediatric radiologists. Data were analysed using agreement (observed, positive and negative) and Cohen's kappa with 95% CIs.

RESULTS

Fifteen participants were recruited into the study in which 600 lower limb joints were clinically examined. Statistical analysis showed excellent inter-rater reliability between podiatrist and paediatric rheumatologist for both joint swelling and tenderness. Results of the intra-rater reliability of the podiatrist using the PE tool indicated excellent percentage agreements (98.5-100%) and substantial kappa coefficients (0.93-1). The inter-rater reliability between radiological assessments contrasted the PE results, showing low agreement and poor reliability. Comparisons between PE and MRI resulted in poor kappa coefficients and low agreement percentages. The most agreeable joint between MRI and PE was the ankle joint, while the worst performing joint was the sub-talar joint.

CONCLUSION

Results indicate potential clinical reliability; however, the validity and diagnostic accuracy of the proposed PE tool remains unclear due to low kappa coefficients and inconsistent agreements between PE and MRI results. Further research will be required before the tool may be used in a clinical setting.

Reporting of Research Ethics in Studies Focusing on Foot Health in Patients with Rheumatoid Arthritis - A Systematic Review

Research ethics is a fundamental part of the entire research. Patients with rheumatoid arthritis are sensitive group of research participants because their long-term health problems cause significant changes in their foot health. In foot health research, data are usually collected through a clinical assessment of the foot or questionnaires. However, there is limited evidence of the reported research ethics of empirical studies on foot health in patients with rheumatoid arthritis. Therefore this review aimed to analyze the reported research ethics of peer-reviewed empirical studies focusing on foot health in patients with rheumatoid arthritis as research participants. This systematic review used the Medline/PubMed, CINAHL, and Embase databases. A total of 1,653 records were identified, and 32 articles were included in the final analysis. Reporting research ethics in studies of patients with rheumatoid arthritis is fragmented, focusing predominantly on ethical approval and informed consent and lacking a broader discussion about research ethics.

Effectiveness of custom-made foot orthoses in patients with systemic lupus erythaematosus: protocol for a randomised controlled trial

INTRODUCTION

Systemic lupus erythaematosus (SLE) is a chronic autoimmune disease of heterogeneous involvement. The disease may affect feet with a high prevalence of symptoms such as, for example, pain, forefoot and rearfoot deformities, and biomechanics dysfunctions. Custom-made foot orthoses (CMFO) have been previously reported to be effective in patients with other rheumatic diseases. However, as far as the authors know, there exist no studies about their effectiveness in SLE. This study aims at determining the effect of CMFO versus placebo flat cushioning insoles on pain, foot functionality, fatigue and quality of life in patients with SLE.

METHODS AND ANALYSIS

A randomised controlled trial would compare the effects of (1) CMFO and group B, which received a placebo, flat cushioning insoles, for 3 months. The main outcome measures are foot pain, foot functionality and foot-related disability. The secondary outcome measures are fatigue and quality of life.

ETHICS AND DISSEMINATION

The study has been approved by the Portal de Ética de la Investigación Biomédica de Andalucía ethical committee 1494-N-19. The results will be disseminated regardless of the magnitude or direction of effect.

TRIAL REGISTARTION NUMBER

Clinicaltrials.gov identifier NCT04098055.

Effectiveness and Duration of Plantar Pressure Off-loading by Two Designs of Felt Padding: A Preliminary Study

BACKGROUND

The aim of this study was to observe the pressure changes in the felt padding used to off-load pressure from the first metatarsal head, the effects obtained by different designs, and the loss of effectiveness over time.

METHOD

With a study population of 17 persons, two types of 5-mm semicompressed felt padding were tested: one was C-shaped, with an aperture cutout at the first metatarsophalangeal joint, and the other was U-shaped. Pressures on the sole of the foot were evaluated with a platform pressure measurement system at three time points: before fitting the felt padding, immediately afterward, and 3 days later.

RESULTS

In terms of decreased mean pressure on the first metatarsal, significant differences were obtained in all of the participants (P < .001). For plantar pressures on the central metatarsals, the differences between all states and time points were significant for the C-shaped padding in both feet (P < .001), but with the U-shaped padding the only significant differences were between no padding and padding and at day 3 (P = .01 and P = .02).

CONCLUSIONS

In healthy individuals, the U-shaped design, with a padding thickness of 5 mm, achieved a more effective and longer-lasting reduction in plantar pressure than the C-shaped design.

Effectiveness of custom-made foot orthoses in patients with rheumatoid arthritis: a randomized controlled trial

OBJECTIVE:

To determine the effect of custom-made foot orthoses versus placebo insoles on pain, disability, foot functionality, and quality of life.

DESIGN:

Double-blinded randomized controlled trial.

SETTING:

University Podiatric Clinical Area.

SUBJECTS:

Patients with rheumatoid arthritis.

INTERVENTIONS:

Patients were randomly assigned to either group A, which received custom-made foot orthoses, or group B, which received placebo, flat cushioning insoles, for three months.

MAIN MEASURES:

The primary outcome was foot pain, measured by visual analog scale. Foot functionality, foot-related disability, and quality of life were measured using the Foot Function Index, the Manchester Foot Pain and Disability Index, and 12-Item Short Form Health Survey (SF-12) questionnaires, respectively, at the beginning and at days 30, 60, and 90.

RESULTS:

A total of 53 patients, aged 59.21 ± 11.38 years, received either the custom-made foot orthoses ( N = 28) or the placebo ( N = 25). For the analysis of the data, only participants who had been measured at the four time points (0, 30, 60, and 90 days) were included. In group A, all variables showed statistically significant differences when comparing the initial and final measurements. Pain showed 6.61 ± 2.33 and 4.11 ± 2.66 in group A, at baseline and at 90 days, respectively, and Group B showed 6.16 ± 1.77 and 5.60 ± 2.71 at baseline and at 90 days, respectively. This was the only variable that showed statistically significant difference between groups ( P = 0.048).

CONCLUSION:

The custom-made foot orthoses significantly reduced the participants' foot pain, although they did not have positive effects on disability, foot functionality, and quality of life compared with only cushioning.

Effect of a thin customized insole on pain and walking ability in rheumatoid arthritis: A randomized study

OBJECTIVE

The aim of the study was to investigate the immediate effects of a thin, easily customizable insole on pain and walking ability in patients with rheumatoid arthritis (RA) who have forefoot pain, and to determine whether the insoles were in use 1 year afterwards.

DESIGN

An experimental, assessor-blinded design was applied to compare the immediate effects when walking with or without insoles in random order. After 1 year, a structured telephone interview was conducted.

PARTICIPANTS

Twenty-one subjects with RA and foot pain in at least one forefoot when walking and in response to the Gänslen test were recruited consecutively from the outpatient clinic and the inpatient ward at a hospital for people with rheumatic disease.

INTERVENTION

Each subject was given a 4-mm thin individually customized insole of a malleable plastic material (CI-Core®) with synthetic textile material on the upper side.

MAIN OUTCOME MEASURES

The 6-min walk test (6MWT) was used to assess the ability to walk, and a 10-cm visual analogue scale to measure the intensity of foot pain induced by walking with and without the insole. A standardized questionnaire with five items was used to determine the use of, and degree of satisfaction with, insoles after 1 year.

RESULTS

The median (interquartile range) foot pain intensity was 19 (15) with and 36 (27) without insoles (p < 0.001; effect size = 0.6). No statistically significant differences in 6MWT were found between the presence or absence of insoles (p = 0.07). After 1 year, 90% of the participants were still using the insoles.

CONCLUSIONS

The use of thin, easily customizable insoles resulted in immediate clinically relevant relief in walking-induced forefoot pain. Most of the patients were still using the insoles after 1 year.

Effectiveness of preformed foot orthoses in reducing lower limb pain, swollen and tender joints and in improving quality of life and gait parameters in children with juvenile idiopathic arthritis: a randomised controlled trial (Protocol)

BACKGROUND

Many children and adolescents with juvenile idiopathic arthritis experience lower limb problems which may lead to physical disabilities significantly impacting on their quality of life and symptoms. Emerging evidence has identified the effective role of podiatry in the management of juvenile idiopathic arthritis, suggesting the clinical benefit of different orthotic therapies.

METHODS

This study will be a parallel-group designed, multicentre, randomised controlled trial, aiming to recruit 66 children and adolescents with juvenile idiopathic arthritis aged between 5 and 18 years. Those recruited will need to be diagnosed according to the International League of Associations for Rheumatology criteria, and present with lower limb joint pain, swelling and/or tenderness. Participants will be recruited from three outpatient hospital clinics in New South Wales, Australia. Participants will be randomly allocated to receive a trial or control intervention. The trial group will be prescribed a customised preformed foot orthoses; instead, the control group will receive a flat 1 mm insole with no corrective modifications. Primary outcome measure recorded will be pain. Secondary outcomes will be quality of life, foot disability, swollen and tender joint count and gait parameters (such as plantar pressures, walking speed, stance and swing time). The allocated foot orthoses will be worn for 12 months, with data collected at baseline, 4 weeks, 3, 6 and 12 months intervals. Group allocation will be concealed and all analyses will be carried out on an intention to treat.

DISCUSSION

The purpose of this trial is to explore the efficacy of a cost-effective, non-invasive podiatric intervention that will be prescribed at the initial biomechanical consultation. This approach will promote early clinical intervention, which is the gold standard in paediatric rheumatology. Furthermore, this study has the potential to provide new evidence for the effectiveness of a mechanical intervention alone to reduce swollen and tender joints in juvenile idiopathic arthritis.

TRIAL REGISTRATION NUMBER

This clinical trial has been registered with the Australian New Zealand Clinical Trials Registry: ACTRN12616001082493p. Ethics for this randomised controlled trial has been approved (16/09/21/4.03).

Foot orthoses in the management of chronic subtalar and talo crural joint pain in rheumatoid arthritis

BACKGROUND

This pilot study investigated whether semi-rigid and soft orthoses had an effect on pain, disability and functional limitation in participants with chronic rheumatoid hindfoot involvement.

METHODS

Participants with chronic hindfoot pain were randomly assigned to 2 groups, commencing either with semi-rigid Subortholene orthoses or soft EVA orthoses. The Foot Function Index and the Ritchie Articular Index were administered pre- and post-intervention, which lasted for 3 months. Following a 2 week washout period, each group was switched over to the other type of orthoses.

RESULTS

Nine female participants (mean age 52.2years (SD 9.1); mean weight 71kg (SD 12.64); mean height 160cm (SD 5.18)) with a mean RA duration of 11.7years (SD 7.83), and a mean ankle/subtalar joint pain duration of 5.7years (SD 2.62), completed the programme. Mean improvement in FFI score for both orthoses resulted in the same statistical significance (p=0.001). Statistically significant reduction in pain, disability and functional limitation was observed for both interventions, together with improvement in the Ritchie Articular Index score.

CONCLUSION

Both Subortholene and EVA orthoses significantly reduced pain, disability and functional limitations in participants with chronic ankle/subtalar joint pain in rheumatoid arthritis.