Forefoot disease activity in rheumatoid arthritis patients in remission: results of a cohort study

Differences and Similarities in the Feet of Metatarsalgia Patients with and without Rheumatoid Arthritis in Remission

Objectives: Metatarsalgia continues to be a problem in patients with rheumatoid arthritis (RA) in remission (remRA), as well as in the non-rheumatic population, with a mechanical origin. Identify and compare clinical, morphological, disability, synovitis (ultrasound), and radiological osteoarticular damage characteristics in two groups of patients with lesser-ray metar-tarsalgia, with remRA, and without RA. Methods: Cross-sectional study with 84 patients with remRA (mRA) and 60 patients without RA (nmRA). The study evaluated five clinical variables (pain, Foot Function Index (FFI), joint mobility, digital deformities, and foot type), a radiological variable (osteoarticular damage), and an ultrasound variable (metatarsal synovitis). The data were analysed using descriptive and correlational techniques. Results: There were no significant differences in sex, age, body mass index (BMI), or degree of pain. Both groups showed a high prevalence of limited joint mobility for the ankle and first metatarsal phalanx (DF1st MTPJ) and digital deformities, with no statistically significant differences. Similarly, there were no differences in lesser-ray synovitis. On the other hand, there were differences in mRA with greater disability and activity limitation (FFI), LDD (lesser-ray digital deformities) stiffness, first-ray deformities, radiological damage, synovitis in 1st MTPJ, and positive Doppler (five patients). Conclusions: Metatarsalgia presents similarities in both populations. Biomechanical factors may influence the symptoms and presence of synovitis in patients with RA in remission. Other characteristics are more frequent in mRA, which could be related to the disease; thus, future research should include both biomechanical and ultrasound exploration of the foot in the valuation of patients in remission.

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.

Patients' and clinicians' perspectives on the clinical utility of the Rheumatoid Arthritis Foot Disease Activity Index

Although patient-reported outcome measures (PROMs) are recommended in clinical practice, their application in routine care is limited. The Rheumatoid Arthritis Foot Disease Activity Index (RADAI-F5) is a validated PROM for assessing foot disease in rheumatoid arthritis (RA). To explore patient and clinician opinions and perceptions of the clinical utility of the Rheumatoid Arthritis Foot Disease Activity Index (RADAI-F5), eight RA patients and eight clinicians routinely involved in the management of RA patients participated in one semi-structured remote video-based interview. They provided their perspectives on the barriers and facilitators to clinical implementation of the RADAI-F5. Three global themes were identified; 'Feet are a priority' as the impact of RA on the feet negatively impacted upon patient quality of life. The second theme was 'Need for a clinically feasible foot PROM' as participants recognised the current lack of a clinically feasible tool to determine RA foot disease. The third global theme of 'Implementation' was drawn together to form two subordinate themes: 'Facilitators to RADAI-F5 implementation' as the tool can promote communication, guide management, help screen foot symptoms, monitor foot disease status and treatments, and promote patient education and; 'Barriers to RADAI-F5 implementation' as there were associated practical difficulties, including lack of appointment time, administrative burdens, IT barriers and preference for further RADAI-F5 validation using imaging. The RADAI-F5 has significant potential as a clinical tool to aid foot disease management. However, implementation challenges must be overcome before broad adoption in rheumatology clinics.

Implication and utility of DAS-28 squeeze in rheumatoid arthritis: an Indian experience

The purpose of this study was to compare and correlate disease activity score including 28 joints counts (DAS-28) Squeeze with DAS-28 and clinical disease activity index (CDAI) to assess disease activity (DA) in rheumatoid arthritis (RA) patients. A total of 100 RA patients were included in the study. All subjects were evaluated for disease activity using the DAS-28 Squeeze, DAS-28, and CDAI. Spearman’s rho (ρ) was calculated to determine the correlation between DAS-28 Squeeze, DAS-28, and CDAI. Cross-tabulation was performed to compare and calculate the kappa coefficient for the link between two indices. For each scale, Cronbach’s alpha was also calculated to test dependability. The average age of the study group was 43.9±11.3. The mean scores on the DAS-28 Squeeze, DAS-28, and CDAI were, respectively, 3.58±1.06, 5.06±1.56, and 22.81±14.92. p=0.001 indicated a significant correlation between DAS-28 Squeeze and DAS-28 (ρ=0.986) and CDAI (ρ=0.939) for DAS-28 Squeeze. There was a considerable correlation between all three measures at various DA levels. Cronbach’s alpha for DAS-28 Squeeze, DAS-28, and CDAI were respectively 0.716, 0.663, and 0.734. DAS-28 Squeeze exhibited a substantial positive association with DAS-28 and CDAI for assessing disease activity and appears to be a more useful and reliable method than DAS-28 and CDAI for monitoring disease activity in RA patients.

Unterschiede in der Therapie entzündlich rheumatischer und degenerativer Füße. Die Vorfußchirurgie

Der Unterschied zwischen rheumatischen und degenerativen Veränderungen am Fuß liegt in der fortschreitenden Destruktion der Gelenke bei persistierender Synovialitis der rheumatoiden Arthritis (RA). Unter der heute wirksameren immunsuppressiven Therapie und eines frühen und aggressiven Beginns zeigen sich mildere Verlaufsformen. So können zunehmend auch gelenkerhaltende Verfahren der Vorfußchirurgie Anwendung finden. Entscheidend ist hier jedoch die Remission mit sicherer Krankheitskontrolle für den gelenkerhaltenden Eingriff. Dennoch ist das Rezidiv- und Fehlstellungsrisiko aufgrund wiederkehrender arthritischer Phasen höher. Rheumaorthopädische Standardverfahren, wie die Arthrodese des Großzehengrundgelenkes mit Resektion der Metatarsaleköpfchen haben aber Ihren Stellenwert beim Vollbild des erosiven rheumatischen Vorfußes nicht verloren. Ein standardisiertes Vorgehen fehlt. Umso wichtiger ist es, mit jedem Patienten individuell die richtigen Maßnahmen zu festzulegen.

Pedobarographic Measurements of Rheumatoid Feet Compared with Clinical Parameters

Objective:

This study aimed to investigate the relationship between plantar pressure pedobarographic measurements and disease activity, radiological abnormalities, and foot indexes in patients with rheumatoid arthritis (RA).

Methods:

Sociodemographics, foot symptoms, anatomical distribution, pain intensity and duration, and podiatry services access data were collected. Disease activity scale of 28 joints (DAS28) was used for the disease activity, and Health Assessment Questionnaire (HAQ) was used for the functional status. Foot function index (FFI) was used to measure the impact of foot pathology on its function. The Modified Larsen scoring was used to assess radiological abnormalities. Pedobarographic measurements were used to analyze foot loading characteristics.

Results:

A total of 104 feet of 52 patients with RA was evaluated. DAS28 scores did not correlate with the plantar pressure values (p>0.05). A significant correlation was found between HAQ scores and right medial midfoot loading pressure (r=0.355; p<0.01). FFI scores were positively correlated with right lateral midfoot loading pressure (r=0.302; p<0.05). No relationship was found between Manchester Foot Pain and Disability Index and plantar loading characteristics. The radiological scores were correlated with left lateral hindfoot plantar pressure (r=0.286; p<0.05).

Conclusions:

Pedobarographic measurements can be considered as a follow-up evaluation tool for the evaluation of all foot parts (forefoot, midfoot, and hindfoot). Rheumatoid feet investigation showed that foot involvement is independent of the disease duration, whereas midfoot plantar pressures are associated with the body mass index. Additionally, DAS28 may fall short as a marker of disease activity because it neglects foot problems.

How reliable is assessment of joint swelling and tenderness over socks or stockings in patients with established rheumatoid arthritis?

OBJECTIVES

Physicians tend to omit examinations of the foot and ankle in routine practice because it consumes a lot of time when working within tight time constraints. Although barefoot examination is critical to assess disease activity of rheumatoid arthritis (RA), we think occasional examination of foot over socks or stockings is better than not examining foot at all. The aim of this study was to assess the accuracy of foot examinations over socks or stockings in patients with RA.

METHODS

Sixty patients with RA were enrolled in this study. A rheumatologist and a senior resident performed foot examinations on each patient over socks, over stockings, and on bare foot to assess swelling and tenderness. Concordance rates between the barefoot examination and the examinations over socks or stockings by each examiner were investigated.

RESULTS

The rheumatologist had a concordance rate of 94.4% over socks and 98.8% over stockings. The senior resident had a concordance rate of 95.6% over socks and 98.5% over stockings.

CONCLUSIONS

Foot examinations over socks and stockings had high concordance rates with the barefoot examination, and it may be an option for decreasing foot and ankle examination time in RA patients.

Ultrasonography-detected synovitis of hand is associated with the presence of synovitis in the forefoot of patients with rheumatoid arthritis

BACKGROUND

In rheumatoid arthritis, forefoot disease activity can lead to joint damage, pain, and disability during weight-bearing activities; therefore, the evaluation and control of forefoot disease activity is important. We aimed to investigate an association between the prevalence of abnormalities in the forefoot based on ultrasonography (US) and the clinical and US findings related to arthritis and identify factors related to the presence of synovitis in the forefoot of RA patients.

METHODS

In total, 810 metatarsophalangeal joints of 81 rheumatoid arthritis patients were examined using US. Patients were assigned to either a forefoot synovitis group (n = 22), with foot synovitis detected using US, or a non-forefoot synovitis group (n = 59). We assessed associations between clinical parameters and US finding of the hand and US finding of the metatarsophalangeal joints.

RESULTS

The following were significantly higher in forefoot synovitis group than in non-forefoot synovitis group: swollen joint count [P < 0.001]; Disease Activity Score 28 based on C-reactive protein [P < 0.05]; clinical disease activity index [P < 0.001]; and total Power Doppler score of the hand [P < 0.001]. Receiver-operating characteristic analysis for total Power Doppler scores of the hand to suggest the presence of synovitis in the metatarsophalangeal joints showed that a total Power Doppler score of the hand of ≥5 was associated with synovitis in the metatarsophalangeal joints, with a sensitivity of 68% and a specificity of 85% (odds ratio = 11.9).

CONCLUSION

Total Power Doppler scores of the hand had a good valuable score for suggesting the presence of synovitis in metatarsophalangeal joints of rheumatoid arthritis patients.

Measuring Inflammatory Foot Disease in Rheumatoid Arthritis: Development and Validation of the Rheumatoid Arthritis Foot Disease Activity Index-5

OBJECTIVE

Omission of foot joints from composite global disease activity indices may lead to underestimation of foot and overall disease in rheumatoid arthritis (RA) and under-treatment. The aim of this study was to evaluate the measurement properties of the Rheumatoid Arthritis Foot Disease Activity Index-5 (RADAI-F5), a newly developed patient-reported outcome measure for capturing foot disease activity in people with RA.

METHODS

Participants with RA self-completed the RADAI-F5, modified Rheumatoid Arthritis Disease Activity Index (mRADAI-5), Foot Function Index (FFI), and Foot Impact Scale (FIS) impairment/footwear and activity/participation subscales. The 28-joint Disease Activity Score using the erythrocyte sedimentation rate (DAS28-ESR) was also recorded. Subgroups completed the RADAI-F5 at 1 week and 6 months. Psychometric properties, including construct, content and longitudinal validity, internal consistency, 1-week reproducibility, and responsiveness over 6 months were evaluated.

RESULTS

Of 142 respondents, 103 were female, with a mean ± SD age of 55 ± 12.5 years and median RA disease duration of 10 (interquartile range 3.6-20.8) months. Theoretically consistent associations confirming construct validity were observed with mRADAI-5 (0.789 [95% confidence interval (95% CI) 0.73, 0.85]), FFI (0.713 [95% CI 0.62, 0.79]), FIS impairment/footwear (0.695 [95% CI 0.66, 0.82], P < 0.001), FIS activity/participation (0.478 [95% CI 0.37, 0.63], P < 0.001), and the DAS28-ESR (0.379 [95% CI 0.26, 0.57], P < 0.001). The RADAI-F5 demonstrated high internal consistency (Cronbach's α = 0.90) and good reproducibility (intraclass correlation coefficient = 0.868 [95% CI 0.80, 0.91], P < 0.001, smallest detectable change = 2.69). Content validity was confirmed, with 82% rating the instrument relevant and easy to understand.

CONCLUSION

The RADAI-F5 is a valid, reliable, responsive, clinically feasible patient-reported outcome measure for measuring foot disease activity in RA.

Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme

Background

Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.

Objectives

To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.

Design

Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.

Setting

Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).

Participants

Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.

Interventions

Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.

Main outcome measures

Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.

Results

Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.

Limitations

The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.

Conclusion

The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.

Future work

Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.

Trial registration

Current Controlled Trials ISRCTN70160382.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Foot and Ankle Problems in Patients With Rheumatoid Arthritis in 2019: Still an Important Issue

Objective

To study the prevalence of foot pain in patients with rheumatoid arthritis (RA) and whether including a 12‐joint foot count in addition to the 28‐joint count (from the Disease Activity Score 28 [DAS28]) improved detection of foot or ankle pain. In addition, the association between the self‐reported foot and ankle score (SEFAS), patient‐reported function, and disease‐specific factors was studied.

Methods

Physician‐reported data (swollen/tender 12‐joint foot count, DAS28, and medication) and patient‐reported data (foot/ankle pain, physical function, global health, and SEFAS) were assessed during a clinical visit. Data were analyzed with t test, χ² tests, and regression analysis.

Results

A total of 320 patients with RA were included (mean age 63 years, SD 13 years; 73% women), of whom 69% reported foot or ankle pain. Patients who reported foot or ankle pain had a lower mean age and worse disease activity, general pain, function, and global health (P ≤ 0.016), and fewer were in remission (50% versus 75%; P < 0.001) compared with patients without foot pain. The 12‐joint foot count identified 3.2% and 9.5% additional patients with swollen and tender joints, respectively, compared with the 28‐joint count. The SEFAS was associated with walking problems (β = −2.733; 95% confidence interval [CI] = −3.963 to −1.503) and worse function (β = −3.634; 95% CI = −5.681 to −1.587) but not with joint inflammation severity.

Conclusion

The prevalence of foot or ankle pain in patients with RA is high. The 12‐joint foot count had minor effects on detecting patients with foot pain. However, the SEFAS contributed additional information on foot problems that was not identified by joint examinations alone.

Prevalence and trajectory of erosions, synovitis, and bone marrow edema in feet of patients with early rheumatoid arthritis

Despite erosions being as prevalent in feet as in hands in patients with rheumatoid arthritis (RA), their development in relation to synovitis and bone marrow edema (BME) have mainly been studied in hands. This study examines the prevalence and longitudinal trajectory of erosions, BME, and synovitis in metatarsophalangeal joints (MTPJs) in patients with early RA over 2 years of treatment. We also describe correlations between erosions, synovitis, and BME at the joint level. Magnetic resonance imaging (MRI) of the most symptomatic forefoot was acquired at baseline, year 1, and ≥ 2 years. Metatarsophalangeal joints 2-5 were scored by a radiologist for erosions, synovitis, and BME according to OMERACT guidelines. Patients were treated per standard of care. Thirty-two patients with early RA were included. Significant reductions in overall synovitis scores, MTPJ2, and MTPJ3 synovitis scores were seen between year 1 and ≥ 2 years. Overall BME scores improved in year 1 and were sustained at ≥ 2 years. BME improved in MTPJ2, MTPJ3, and MTPJ4. Overall erosions did not significantly change. Positive correlations were seen between changes in synovitis and BME in MTPJ2 and MTPJ5. In patients with early RA, standard of care was associated with overall reductions in synovitis by year 2, BME by year 1, and no progression in overall erosion scores on MRI. MTPJ2 and MTPJ3 appeared to be the most active joints. Improvements in synovitis were noted in MTPJ2 and MTPJ3 and reductions in BME in MTPJ2, MTPJ3, and MTPJ4, while other MTPJs did not progress. Key Points • This is one of the few MRI studies that examined longitudinal changes in imaging outcomes in early RA at the joint level in feet. • Erosions, synovitis, and bone marrow edema (BME) visualized on magnetic resonance imaging were most prevalent in metatarsophalangeal joints (MTPJ) 2 and 3 in patients with early rheumatoid arthritis (RA). • Standard of care was associated with improvements in synovitis in MTPJ2 and MTPJ3 and improvements in BME in MTPJ2, MTPJ3, and MTPJ4 over 2 years of treatment.

Distribution of erosions in hands and feet at the time for the diagnosis of RA and during 8-year follow-up

Background

Joint destruction in rheumatoid arthritis (RA) is usually evaluated by radiographs of both hands and feet, while the inflammatory status mostly is evaluated by DAS28 which, however, does not include the feet.

Objectives

To investigate the distribution of erosions in hands and feet in early RA over 8 years and its potential clinical implications. Furthermore, the group of patients never showing erosions has been addressed.

Methods

This study comprises 1041 patients from the BARFOT study of patients with early RA. Radiographs of hands and feet were performed at baseline, 1, 2, 5, and 8 years and evaluated by the Sharp van der Heijde scoring (SHS) method (32 joints in the hands and 12 in the feet). Disease activity was measured by DAS28, SR, CRP, and function with HAQ.

Results

In the feet, there were significantly more eroded joints in percent of examined joints than in the hands at all time points. Patients with erosions only in the feet were younger, more often seropositive and smokers. They had significantly lower baseline DAS28, than the patients with erosions only in the hands. The patients without erosions over time were, at diagnosis, significantly younger and less frequently seropositive compared with patients having erosions.

Conclusions

This study highlights the importance of evaluating the feet in patients with RA, both with clinical examinations and with imaging and lends support to the notion that seropositivity and smoking are risk factors for erosive disease. Further studies of patients with nonerosive disease are needed.

Key Points: • Foot problems are common in RA • This study emphasizes the limitations of DAS28 and Sharp van der Heijde score as regards evaluating disease activity and radiographic damage • This study highlights the importance of evaluating the feet in patients with RA with clinical examinations and imaging • This study also points out the need of further studies of patients with non-erosive RA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10067-020-05465-x.

Prevalence of feet and ankle arthritis and their impact on clinical indices in patients with rheumatoid arthritis: a cross-sectional study

Background

We aimed to evaluate the prevalence of foot and/or ankle arthritis (FAA) and its impact on clinical indices in patients with rheumatoid arthritis (RA).

Methods

This cross-sectional study used data from the Korean College of Rheumatology Biologics & Targeted therapy registry to observe clinical outcomes of patients undergoing biologics therapy and conventional therapy. FAA was defined as ≥1 tender or swollen joint in the ankle and/or 1st-5th metatarsophalangeal (MTP) joints. Disease Activity Score 28 (DAS28), Routine Assessment of Patient Index Data 3 (RAPID3), Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI) were assessed.

Results

Among 2046 patients, 598 had FAA. The ankle joint was the most commonly involved joint in FAA (tender joint, 71.4%; swollen joint, 59.5%), followed by the third and second MTP joints. Patients with FAA showed higher DAS28, RAPID3, SDAI, and CDAI scores. FAA presence was significantly associated with non-remission as per DAS28-ESR (odds ratio, 3.4; 95% confidence interval, 2.0–5.8), DAS28-CRP (3.6, 2.4–5.3), SDAI (6.3, 2.8–14.6), CDAI (7.6, 2.4–24.3), and RAPID3 (5.6, 2.7–11.5) indices on adjusting for age, sex, disease duration, presence of rheumatoid factor, presence of anti-cyclic citrullinated peptide antibody, lung disease, use of methotrexate, and previous use of biological disease-modifying anti-rheumatic drugs. Patients with FAA were less likely to achieve remission of SDAI (n = 6, 1.0%) and CDAI (n = 3, 0.5%) than that of DAS28-ESR (n = 21, 3.5%), DAS28-CRP (n = 38, 6.4%), and RAPID3 (n = 12, 2.0%).

Conclusions

FAA represents a severe disease activity and is an independent risk factor for non-remission in patients with RA.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2773-z) contains supplementary material, which is available to authorized users.

Foot orthoses for people with rheumatoid arthritis: a survey of prescription habits among podiatrists

Background

Guidelines recommend foot orthoses for people with both early (< 2 years) and established rheumatoid arthritis (RA). While prefabricated foot orthoses are cheaper and can exhibit comparable effects to customised devices, the available evidence for their effectiveness is inconsistent. Little is known about what types of foot orthoses clinicians prescribe. This study describes the foot orthoses prescription habits of podiatrists for people with rheumatoid arthritis.

Methods

One hundred and eighty-three podiatrists from the United Kingdom (UK) (n = 88), Australia (n = 68) and New Zealand (n = 27) completed a self-administered, online survey regarding the types of foot orthoses prescribed in clinical practice for people with RA. This study forms part of a wider international survey exploring foot orthosis prescription habits.

Results

UK respondents were more likely to prescribe prefabricated orthoses for early RA (n = 47, 53%) and customised orthoses for established RA (n = 47, 53%). Respondents in Australia were more likely to prescribe customised orthoses for both early (n = 32, 47%) and established (n = 46, 68%) RA, whilst respondents in New Zealand were more likely to prescribe prefabricated orthoses for both early (n = 16, 59%) and established (n = 10, 37%) disease.

Irrespective of disease stage, the use of foam impression boxes was more prevalent in the UK and New Zealand when capturing a model of the feet prior to manufacturing customised orthoses. In contrast, electronic scanning and plaster of Paris were more common in Australia. Computer aided manufacture was utilised more frequently among respondents in Australia than in the UK and New Zealand. Respondents in all three countries specified more flexible shell materials for established RA, compared to early disease. Cushioning top covers (e.g. PORON® or polyurethane) were most frequently specified in all countries for both disease stages.

Conclusions

Considerable variation was seen in the self-reported foot orthoses prescription habits of respondents for people with RA. Variation between countries and disease stage was seen in type of orthoses, specific brands, manufacturing methods, and materials prescribed. The results allow podiatrists and broader health service providers to compare their practice against reported national and international patterns.

Electronic supplementary material

The online version of this article (10.1186/s13047-019-0314-5) contains supplementary material, which is available to authorized users.

Features of patients with rheumatoid arthritis whose debut joint is a foot or ankle joint: A 5,479-case study from the IORRA cohort

Background

Foot and ankle joint disorders are serious issues for patients with rheumatoid arthritis (RA). We compared the differences between patients with RA whose first symptom involved a foot or ankle joint (FOOT group) versus other joints (non-FOOT group) within the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort in our institute.

Patients and methods

In the IORRA survey conducted in April 2016, patients were invited to complete six questionnaires about their first symptom at RA onset, current foot or ankle symptoms, daily living activities, and mental health. Disease activity, clinical laboratory variables, functional disability, quality of life, use and ratio of anti-inflammatory and antirheumatic drugs, daily living activities and mental health were compared between the two groups.

Results

Among 5,637 Japanese patients with RA who participated in the IORRA survey on April 2016, 5,479 (97.2%) responded to the questionnaire regarding their debut joint. Of these patients, 2,402 (43.8%) reported that their first symptom of RA involved a foot or ankle joint. The FOOT group (n = 2,164) had higher disease activity, higher disabilities, lower quality of life, lower activities of daily living, and poorer mental health and used anti-inflammatory drugs at a higher rate and at higher doses compared with the non-FOOT group (n = 2,164). On the other hand, the use of medications to suppress the disease activity of RA was similar between the groups.

Conclusion

Clinicians should pay more attention to foot and ankle joints in daily practice so as not to underestimate the disease activity of RA.

Multidisciplinary recommendations for diagnosis and treatment of foot problems in people with rheumatoid arthritis

BACKGROUND

Foot problems in people with rheumatoid arthritis (RA) are highly prevalent and have a substantial impact on quality of life. Healthcare professionals from various professions can be involved in the management of these foot problems. There is currently no consensus on optimal management. Therefore, the aim of the present study was to develop multidisciplinary recommendations for the management of foot problems in people with RA in the Netherlands.

METHODS

The recommendations were based on research evidence and consensus among experts, following published strategies for the development of practice recommendations. The expert group was composed of 2 patients and 22 experienced professionals (rheumatologists, rehabilitation physicians, orthopaedic surgeons, specialized nurses, podiatrists, orthopaedic shoe technicians, pedicurists, and researchers) in the Netherlands. For each developed recommendation i) the level of evidence was determined, and ii) the level of agreement (among the expert group) was set by an anonymous voting procedure using a numeric rating scale. The mean and range of the level of agreement for each recommendation was calculated. A recommendation was approved when ≥70% of the expert group voted an NRS-agreement ≥7.

RESULTS

In total, 41 recommendations were developed. Two recommendations concerned a framework for diagnosis and treatment. Thirty-nine recommendations on foot care were developed: seven on diagnosis (including check-ups of feet and shoes and diagnostic imaging), 27 on treatment (including corticosteroid injections, foot surgery, therapeutic shoes, foot orthoses, exercise therapy, toe-orthoses and toenail-braces, treatment of toenails and skin), four on communication, and one on organisation of RA-related footcare. All recommendations were approved by the expert group. The percentage score of NRS-agreement ≥7 ranged from 80 to 100%.

CONCLUSIONS

These are the first published multidisciplinary recommendations specific to the management of foot problems in people with RA. Multidisciplinary recommendations can provide guidance in timely referrals and access to adequate footcare. More research is needed to strengthen the evidence on diagnosis and treatment of RA-related foot problems. These national recommendations may be a first step towards developing international multidisciplinary recommendations for the management of foot problems in RA.

Effectiveness of foot orthoses in patients with rheumatoid arthritis related to disability and pain: a systematic review and meta-analysis

BACKGROUND

Epidemiological studies consistently report a 90% prevalence of foot pain. Mechanical and other non-pharmacological interventions such as orthoses and footwear can play an important role in managing foot pathology in patients whose systemic disease is controlled. The effectiveness of treatment with insoles has been examined in various randomised controlled trials, which have reported immediate clinical improvements, with reduced foot pain and disability and enhanced functionality. The aim of this systematic review is to determine the effectiveness of foot orthoses in patients with rheumatoid arthritis (RA), in comparison with other treatments, in terms of enhanced disability and reduced pain.

METHODS

A systematic review and meta-analysis was conducted of a number of randomised controlled trials focusing on patients with RA. The search was conducted in Cochrane, CINAHL, PubMed, EMBASE, SCOPUS and Cuiden, by means of an independent peer review. The Mesh terms and fields used were foot, ankle, joint, RA, foot, orthosis, insole and foot orthosis.

RESULTS

Of the initial 118 studies considered, 5 were included in the final systematic review and meta-analysis. These five studies had enrolled a total of 301 participants, with follow-up periods ranging from 4 to 36 months. Although the use of orthoses seems to alleviate foot pain, our meta-analysis did not reveal statistically significant differences between control and intervention groups regarding long- and short-term pain relief and/or reduced disability.

CONCLUSIONS

Foot orthoses can relieve pain and disability and enhance patients, but no significant differences were found between control and intervention groups.

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.

Prevalence, impact and care of foot problems in people with rheumatoid arthritis: results from a United Kingdom based cross-sectional survey

Background

Foot symptoms in rheumatoid arthritis (RA) derive from a combination of inflammation, altered foot mechanics, deformity and secondary skin lesions. Guidelines recommend regular review of patients’ feet, but the extent to which the general population of RA patients report foot symptoms and access foot care has not been established. The aims of this study were to determine the prevalence, impact and care of foot problems in all patients with RA in one geographical area and identify factors associated with accessing foot care.

Methods

Cross-sectional survey of a random sample of patients with RA, who resided within a single community-based National Health Service (NHS) podiatry service. The questionnaire collected demographic data (age, gender, local deprivation score), clinical data (disease duration, arthritis medications, disability (Health Assessment Questionnaire (HAQ)), current foot problems, foot care accessed (podiatry, orthotics and/or orthopaedics) and care received, measures of impact (Foot Impact Scale) and ability to work.

Results

Of 1003 total eligible patients in the target population, 739 were posted survey packs. Of these 413 (56%) replied. Responders and non-responders had similar age (63.5 yr. vs.61.5 yr), gender (74.1%F vs. 75.2%F), and highest deprivation category (13.3% vs.15.9%). Of the responders 92.1% reported current foot problems: articular 73.8%, cutaneous lesions 65.4%, structural 57.6%, extra-articular 42.6%. Responders’ median (IQR) disease duration 10 (5–20) years, HAQ 1.5 (0.75–2.0), FIS_IF 10 (6–14) and FIS_AP 16 (7–23) and 37.8% reported impacts on work. While 69.5% had accessed foot care there were differences in the route of access (by gender and whether independent or NHS provision) and were older (64.9 yr. vs 60.4 yr. p = 0.001), had longer disease duration (12 yr. vs 7 yr. p < 0.001) and had a greater proportion of females (72.2% vs 61.7% p = 0.04) than those who had not accessed care.

Conclusions

Current foot problems were reported by 92.1% of the study sample and substantially impacted on life and work. While overall access to foot care was higher than anticipated, routes of access differed and extent of current problems suggests the provision of effective, timely and targeted care is a pressing need.

Electronic supplementary material

The online version of this article (10.1186/s13047-017-0229-y) contains supplementary material, which is available to authorized users.

Active Foot Synovitis in Patients With Rheumatoid Arthritis: Unstable Remission Status, Radiographic Progression, and Worse Functional Outcomes in Patients With Foot Synovitis in Apparent Remission

OBJECTIVE

To determine whether foot synovitis is associated with adverse radiographic and functional outcomes after 3 years in an inception rheumatoid arthritis (RA) cohort receiving treat-to-target combination disease-modifying antirheumatic drug therapy.

METHODS

Disease activity was assessed in early RA patients (n = 266) using the Disease Activity Score in 28 joints, Clinical Disease Activity Index (CDAI), and Simplified Disease Activity Index (SDAI). Radiographic outcomes were assessed with annual hand and feet radiographs and quality of life with the Short Form 36 (SF-36). The prevalence of remission and foot synovitis was calculated using marginal binomial generalized estimating equations, transition between remission and nonremission states by a multistate Markov model, and changes in radiographic scores by a negative binomial mixed regression log-link model. Population-matched SF-36 data were analyzed by mixed-effects linear regression.

RESULTS

Disease activity scores that omit foot joints were modest in their ability to capture foot synovitis. Despite the relative stringency of the SDAI and CDAI for remission, 25-36% of patients in remission had foot synovitis. In patients in remission, foot synovitis predicted transition from remission into relapse by up to 2-fold. The sustainability of remission markedly influenced the progression of erosion scores (P = 0.006). After adjusting for disease activity, foot synovitis was associated with worse SF-36 physical functioning scores (P = 0.025).

CONCLUSION

Disease activity measures that omit foot joints capture foot synovitis poorly. When it is used to define remission, foot synovitis is found in a substantial proportion of patients, which predicts relapse and worse physical function. Foot synovitis influences the sustainability of remission, which in turn markedly influences radiographic progression. Regardless of remission status, persistent foot synovitis should prompt therapy escalation in order to improve long-term outcomes.

Experiences of mobility for people living with rheumatoid arthritis who are receiving biologic drug therapy: implications for podiatry services

BACKGROUND

Despite significant advancements in new treatment modalities for rheumatoid arthritis with biological therapies, foot complications remain a disabling and common feature of the disease. In this study the aim was to explore and describe the personal experiences of people with rheumatoid arthritis in receipt of biologic treatments in a bid to understand the impact of this form of medication on their mobility.

METHODS

An interpretative phenomenological analysis (IPA) was undertaken to explore in depth the individual experience of rheumatoid disease through personal accounts of the patient journey spanning both 'before' and 'after' the instigation of biologic therapy. A purposive sampling strategy was adopted and in-depth semi structured interviews used to facilitate rich, detailed interview data exploring the lived experiences of individuals undertaking biological therapy and the changes to mobility experienced as a result. Thematic analysis was employed with an IPA framework to identify key meanings, and report patterns within the data.

RESULTS

Five people with rheumatoid arthritis participated in the study. The mean disease duration was 20.2 years (range: 6 -32) and all were being treated with biologic therapies. Four key themes emerged from the data: 1) Life before biologic treatment, depicted in accounts as a negative experience characterised by painful and disabling symptoms and feelings of hopelessness. 2) Life with biologic treatment, often experienced as a life changing transition, restoring function and mobility and offering renewed hope. 3) Sense of self, in which the impact of rheumatoid disease and the subsequent changes arising from biologic therapy reveal a profound impact on feelings of personal identity both pre and post biologic therapy; an effect of footwear on self-image emerges as a dominant sub theme; 4) Unmet footcare needs were evident in the patient narrative, where the unrelenting if diminished impact of foot pain on mobility was viewed in the context of problematic access to foot health services.

CONCLUSION

Whilst the findings from this study mirror those within the existing literature, which report improvements in physical function related to biological therapy, foot problems clearly remained an unremitting feature of life for patients with rheumatoid disease, even when in receipt of biologics.

Use of a temporary supramalleolar orthosis to manage foot pain in a patient with rheumatoid arthritis: A case report

BACKGROUND

Rheumatoid arthritis is a chronic inflammatory condition characterized by joint pain, stiffness, and functional disability. Approximately 90% of patients will report symptoms in the foot or ankle during the course of their disease.

CASE DESCRIPTION

A case of a 40-year-old woman with a 12-year history of rheumatoid arthritis referred to outpatient physical therapy with a chief complaint of pain in the lateral rearfoot and forefoot is presented. At the time of the initial examination, the patient reported persistent pain ranging from 3 to 9/10, aggravated when standing and walking during activities of daily living. Treatment consisted of the fabrication of a supramalleolar orthosis that incorporated an in-shoe foot orthosis to address functional limitations and abnormal foot and ankle posture. A home exercise program was prescribed to address potential balance deficits and strength loss following the application of the orthosis.

OUTCOMES

Clinically significant improvements were seen in pain, gait speed, and on the Foot Function Index following the implementation of the orthotic device. The patient returned to standing and walking with minimal symptom limitations.

DISCUSSION

This case report highlights the short-term clinical outcomes when using a supramalleolar orthosis in conjunction with an in-shoe foot orthosis to manage lateral rearfoot and forefoot pain in a patient with rheumatoid arthritis.

Changes in foot function, disease activity, and disability after forefoot resection arthroplasty in patients with rheumatoid arthritis

The purpose of this study was to investigate the changes in foot function, disease activity, and disability in patients with RA after resection arthroplasty of the forefoot (arthroplasty). Arthroplasty was performed on 11 patients with RA. All study patients underwent clinical assessment to measure disease activity (Disease Activity Score in 28 Joints-C-reactive protein, DAS28-CRP), disability (Health Assessment Questionnaire-Disability Index, HAQ-DI) and foot function (Foot Function Index, FFI) at the following stages: preoperatively and 1, 3, and 12 months after surgery. Following arthroplasty, foot function improved significantly, as assessed by FFI total and subscales (pain, disability, and limitation of activity) (P<0.001, P<0.001, P<0.001, and P=0.002, respectively). Disease activity was significantly improved in relation to DAS28-CRP and its subscales of number of swollen joints and patient global assessment (PtGA) (P=0.033, P=0.008, and P=0.038, respectively). There was no significant difference in disability, as assessed by the HAQ-DI and its subscale, HAQ-walking (P=0.150 and P=0.597, respectively). Foot function improved significantly after arthroplasty, and was maintained at 12 months postoperatively. Additionally, our study showed that disease activity and its subscale PtGA improved after arthroplasty.

Patient and clinician views on the quality of foot health care for rheumatoid arthritis outpatients: a mixed methods service evaluation

Background

Feet are often the first site of joint involvement in rheumatoid arthritis (RA) and get progressively worse if unmanaged, leading to permanent disability and negatively impacting patients’ quality of life. Podiatrists are specialists in the assessment, diagnosis and management of foot and ankle problems, however, RA outpatients often rely on referral from rheumatology clinicians to gain access to musculoskeletal podiatry services on the UK National Health Service (NHS). Therefore, the aim of this evaluation was to identify the foot health needs of rheumatoid arthritis patients and if they are being met by rheumatology clinicians.

Methods

A mixed methods approach was used: collecting qualitative data from patients and quantitative data from clinicians. Two focus groups were conducted with nine RA patients from a tertiary rheumatology outpatient clinic in the UK and the data were thematically analysed to inform a clinician survey. Thirteen rheumatology clinicians, from the same centre, completed the online survey. Resultant data were analysed to produce descriptive statistics.

Results

Patient focus group data generated four main themes: (1) need for foot health information, (2) feet ignored during routine consultations, (3) frequency of foot examination and (4) access to podiatry. Survey data highlighted that (i) 69–85 % of clinicians provided patients with foot health information sometimes, (ii) feet were examined in 47 % of routine consultations, (iii) 54 % of clinicians did not examine feet routinely because they are not included in the disease activity score with 28 joints (DAS-28), (iv) 31 % of clinicians referred patients to podiatry upon RA diagnosis, (v) 0 % of clinicians referred patients to podiatry for periodic review, (vi) 54 % of clinicians believed patients will self-report foot problems and (vii) 62 % of clinicians felt competent in foot examination.

Conclusions

RA patients’ foot health needs were not being fully met by rheumatology clinicians. Patients want foot health information and easy access to podiatry services. Rheumatology outpatient consultations need to have a wider focus than the DAS-28 and incorporate foot examination as standard. Clinicians need to ensure they have sufficient training and follow current national foot health guidance to provide optimal foot health care and outcomes for their RA patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-015-0133-2) contains supplementary material, which is available to authorized users.

Surgical management of the forefoot in patients with rheumatoid arthritis - a review article

Foot and ankle pathologies cause a significant disease burden on rheumatoid patients. Forefoot pathologies causes pain, callosities and possibly ulceration, and can cause problems with footwear. Forefoot correction in rheumatoid patients has historically comprised of excision of diseased joints. While satisfaction was high with this procedure, complications, changing expectations and improvement in medical therapy have raised expectation of patients, physicians and surgeons alike. This review assesses the role of joint preserving osteotomies and arthrodesis, as well as associated complications. It also describes the role of the multidisciplinary team in the management of these patients.

Dynamic plantar loading index detects altered foot function in individuals with rheumatoid arthritis but not changes due to orthotic use

BACKGROUND

Altered foot function is common in individuals with rheumatoid arthritis. Plantar pressure distributions during gait are regularly assessed in this patient group; however, the association between frequently reported magnitude-based pressure variables and clinical outcomes has not been clearly established. Recently, a novel approach to the analysis of plantar pressure distributions throughout stance phase, the dynamic plantar loading index, has been proposed. This study aimed to assess the utility of this index for measuring foot function in individuals with rheumatoid arthritis.

METHODS

Barefoot plantar pressures during gait were measured in 63 patients with rheumatoid arthritis and 51 matched controls. Additionally, 15 individuals with rheumatoid arthritis had in-shoe plantar pressures measured whilst walking in standardized footwear for two conditions: shoes-only; and shoes with prescribed custom foot orthoses. The dynamic plantar loading index was determined for all participants and conditions. Patient and control groups were compared for significant differences as were the shod and orthosis conditions.

FINDINGS

The patient group was found to have a mean index of 0.19, significantly lower than the control group's index of 0.32 (p>0.001, 95% CI [0.054, 0.197]). No significant differences were found between the shoe-only and shoe plus orthosis conditions. The loading index was found to correlate with clinical measures of structural deformity.

INTERPRETATION

The dynamic plantar loading index may be a useful tool for researchers and clinicians looking to objectively assess dynamic foot function in patients with rheumatoid arthritis; however, it may be unresponsive to changes caused by orthotic interventions in this patient group.

Advantages of a combined rheumatoid arthritis magnetic resonance imaging score (RAMRIS) for hand and feet: does the RAMRIS of the hand alone underestimate disease activity and progression?

Background

To evaluate a combined rheumatoid arthritis magnetic resonance imaging score (RAMRIS) for hand and foot (HaF-score) in rheumatoid arthritis (RA).

Methods

Magnetic resonance imaging (MRI, 0.2 Tesla) of the dominant hand and foot of 26 ACPA positive RA patients before and 6 months after initiation of methotrexate was obtained. RAMRIS of the hand was complemented by corresponding scoring of the foot (MTP I-V; HaF-score). Disease Activity Score 28 (DAS28) and a tender and swollen joint count (JC) of the joints scored in MRI were recorded. Changes in these scores (Δ) were assessed.

Results

ΔHaF-score correlated significantly with ΔDAS28 (r = 0.820, 95%-CI 0.633-0.916). Correlations to ΔDAS28 were best for changes in the synovitis subscore (0.648) and bone marrow edema (0.703). Correlations to ΔDAS28 were significantly better for of the ΔHaF-score than ΔRAMRIS (0.499, 0.139-0.743, p = 0.0368).

All patients with at least moderate response (EULAR criteria, n = 11) had continuing disease activity on MRI, including five cases with new erosions, three of them at the feet. Improvements of the hand JC or foot JC were seen in 16 and 15 cases, respectively. However, MRI of the hand or feet improved in only 10 and 9 cases, respectively. No patient fulfilled SDAI remission criteria.

Conclusions

The HaF-score identifies patients with continuing disease activity despite clinical response that would have been missed by consideration of the traditional RAMRIS or the DAS28 alone. Response as opposed to remission may be an insufficient goal in RA as all patients showed continuing disease activity, especially at the feet.

Anatomical location of erosions at the metatarsophalangeal joints in patients with rheumatoid arthritis

OBJECTIVE

The aim of this study was to identify the anatomical location of erosions at the MTP joints in patients with RA using high-resolution 3T MRI.

METHODS

In 24 patients with RA, the more symptomatic forefoot was imaged using 3T MRI. T1-weighted, intermediate-weighted and T2-weighted fat-suppressed sequences were acquired through the MTP joints, together with three-dimensional volumetric interpolated breath-hold examination (3D VIBE) and T1-weighted fat-suppressed post-gadolinium contrast sequences. Images were scored for bone erosion in the distal and proximal part of the MTP joints using the RA MRI scoring (RAMRIS) system. The base of the proximal phalanx and the head of the metatarsal were divided into quadrants to determine the location of erosions (octants) in the dorsal-medial, dorsal-lateral, plantar-medial and plantar-lateral regions.

RESULTS

Seventeen females and seven males with a mean age of 55.5 years and disease duration of 10.6 years (range 0.6-36) were included. Eighteen patients were RF positive, the mean 44-joint DAS for CRP and ESR (DAS44CRP and DAS44ESR) were 2.5 (s.d. 0.8) and 2.6 (s.d. 0.9), respectively. In this cohort of patients with RA, irrespective of MTP joint location, octants located in the proximal part (metatarsal) of the joint and the plantar aspect of the joint were more eroded.

CONCLUSION

This is the first study to report the anatomical location of erosions at the MTP joints in patients with RA. We noted that erosions were more commonly seen on the plantar aspect of the metatarsal head in RA, supporting the hypothesis of a relationship between biomechanical demands and bone changes in the forefoot.

Patterns of magnetic resonance imaging of the foot in rheumatoid arthritis: which joints are most frequently involved?

To investigate patterns of inflammatory MRI pathologies of the fore- and midfoot in rheumatoid arthritis (RA) and early RA (ERA) and their changes under therapy. In this prospective study, MRI data of the foot of 39 RA patients (29 female, 10 male; age: 54 ± 13 years; disease duration: 35 ± 37 months; baseline DAS28: 3.0 ± 2.0; medication: 29 DMARD, 1 biological, 9 symptomatic or non-specific treatment) were evaluated for synovitis in 314 joints, bone marrow edema and erosions according to RAMRIS criteria in a total of 585 joints. The change in joint pathology intensity was evaluated on follow-up MRI (time of follow-up: 8 ± 4 months) in 25 patients. Inflammation was generally more frequent in the metatarsophalangeal (MTP) joints (221/292; 76 %) than in the proximal metatarsal (47/292; 16 %) and tarsal bones (24/292; 8 %). The overall most frequently involved joints of the foot were MTP 5 (51/292; 18 %) and 1 (49/292; 17 %). Change under therapy was most frequently seen in the MTP 1 joint. Progress of inflammation in the MTP 1 was more frequently found in ERA patients than in patients with established RA (disease duration >12 months) (p = 0.002). In RA, the MTP joints, primarily MTP 5 and 1, are the predominant sites of inflammatory MRI pathologies of the foot. A change of inflammatory activity under therapy can be most frequently noted in the MTP 1 joint. This information might be helpful to improve effectiveness of MRI-controlled therapy approaches and clinical trials.

Debridement of painful forefoot plantar callosities in rheumatoid arthritis: the CARROT randomised controlled trial

The objective of this study was to evaluate the long-term benefits of sharp scalpel debridement of painful forefoot plantar callosities in rheumatoid arthritis (RA). The null hypothesis: sharp scalpel debridement would offer no additional long-term advantage in terms of pain and function. Sixty-five people with RA were randomised to receive regular sharp scalpel debridement of painful forefoot plantar callosities in conjunction with a combined therapeutic approach or a combined therapeutic approach alone. The primary outcome measure was change at 18 months in participant-reported forefoot plantar pain measured by a 100-mm visual analogue scale (VAS). Secondary outcome measures were recorded at baseline and study exit and included revised Foot Function Index, Health Assessment Questionnaire, Foot Impact Scale and gait parameters. At 18 months, there were no differences between groups for the primary outcome VAS-measured forefoot plantar pain (left foot (F = 0.23, p = 0.635), right foot (F = 2.14, p = 0.148)). Within-group changes were highly significant (treatment arm, difference = 16.9 (95 % confidence interval (CI) 9.4, 24.4), t = 4.6, p < 0.0001; control arm, difference = 17.5 (95 % CI 9.4, 25.5), t = 4.4, p < 0.0001). There was little change in scores of overall function and foot impact in either group and there were no significant changes in gait parameters noted. The long-term effects of sharp scalpel debridement of painful forefoot plantar callosities in people with RA, when used in conjunction with a combined therapeutic approach, produced no additional benefit over the combined therapeutic approach alone. Trial registration http://www.controlled-trials.com/ISRCTN05190231.

Adherence to a treat-to-target strategy in early rheumatoid arthritis: results of the DREAM remission induction cohort

Introduction

Clinical trials have demonstrated that treatment-to-target (T2T) is effective in achieving remission in early rheumatoid arthritis (RA). However, the concept of T2T has not been fully implemented yet and the question is whether a T2T strategy is feasible in daily clinical practice. The objective of the study was to evaluate the adherence to a T2T strategy aiming at remission (Disease Activity Score in 28 joints (DAS28) < 2.6) in early RA in daily practice. The recommendations regarding T2T included regular assessment of the DAS28 and advice regarding DAS28-driven treatment adjustments.

Methods

A medical chart review was performed among a random sample of 100 RA patients of the DREAM remission induction cohort. At all scheduled visits, it was determined whether the clinical decisions were compliant to the T2T recommendations.

Results

The 100 patients contributed to a total of 1,115 visits. The DAS28 was available in 97.9% (1,092/1,115) of the visits, of which the DAS28 was assessed at a frequency of at least every three months in 88.3% (964/1,092). Adherence to the treatment advice was observed in 69.3% (757/1,092) of the visits. In case of non-adherence when remission was present (19.5%, 108/553), most frequently medication was tapered off or discontinued when it should have been continued (7.2%, 40/553) or treatment was continued when it should have been tapered off or discontinued (6.2%, 34/553). In case of non-adherence when remission was absent (42.1%, 227/539), most frequently medication was not intensified when an intensification step should have been taken (34.9%, 188/539). The main reason for non-adherence was discordance between disease activity status according to the rheumatologist and DAS28.

Conclusions

The recommendations regarding T2T were successfully implemented and high adherence was observed. This demonstrates that a T2T strategy is feasible in RA in daily clinical practice.

Foot problems in a group of patients with rheumatoid arthritis: an unmet need for foot care

OBJECTIVES

The aim of this study was to evaluate the foot involvement in a group of RA patients in regard to symptoms, type and frequency of deformities, location, radiological changes, and foot care.

PATIENTS AND METHODS

A randomized selected 100 rheumatoid arthritis (RA) patients were recruited to the study. Data about foot symptoms, duration and location of foot pain, pain intensity, access to services related to foot, treatment, orthoses and assistive devices, and usefulness of therapies were determined by the questionnaire. Radiological changes were assessed according to modified Larsen scoring system. The scores of disease activity scale of 28 joints and Health Assessment Questionnaire indicating the functional status of RA patients were collected from patient files.

RESULTS

A total of 100 RA patients (90 female, 10 male) with a mean age of 52.5 ±10.9 years were enrolled to the study. Eighty-nine of the 100 patients had experienced foot complaints/symptoms in the past or currently. Foot pain and foot symptoms were reported as the first site of involvement in 14 patients. Thirty-six patients had ankle pain and the most common sites of the foot symptoms were ankle (36%) and forefoot (30%) followed by hindfoot (17%) and midfoot (7%) currently. Forty-nine of the patients described that they had difficulty in performing their foot care. Insoles and orthopedic shoes were prescribed in 39 patients, but only 14 of them continued to use them. The main reasons for not wearing them were; 17 not helpful (43%), 5 made foot pain worse (12.8%), and 3 did not fit (7.6%). Foot symptoms were reported to be decreased in 24 % of the subjects after the medical treatment and 6 patients indicated that they had underwent foot surgery. Current foot pain was significantly associated with higher body mass index and longer disease duration, and duration of morning stiffness. The radiological scores did not correlate with duration of foot symptoms and current foot pain (p>0.05) but the total number of foot deformities was found to be correlated with Larsen scores (p<0.05).

CONCLUSION

In our study, foot involvement and foot symptoms were seen frequently in RA but there is an unmet need for provision and monitoring of foot care in patients suffering from this chronic disease.

Quantitative assessment of foot structure in rheumatoid arthritis by a foot digitizer: detection of deformities even in the absence of erosions

OBJECTIVE

Foot involvement is a major feature in rheumatoid arthritis (RA), leading to structural deformities. Methods to allow a 3-dimensional (3-D) evaluation of foot structure in RA to be applicable in daily clinical practice have not been evaluated. This study assessed the use of a foot digitizer, a noninvasive 3-D scanner collecting objective quantitative data of the feet, to evaluate the presence of foot structure abnormalities in an RA outpatient cohort.

METHODS

Foot digitizer data of RA patients were compared with healthy controls. Subanalyses were performed to find relationships with erosive disease and the presence of swollen and/or tender joints. Linear mixed models were applied with correction, including sex, age, body weight and height, foot length, Disease Activity Score in 28 joints, and disease duration.

RESULTS

Forty-one percent of the patients showed >1 abnormal parameter, measured with the 3-D foot scanner. Most differences found were located in the forefoot, the most frequently affected area of the RA foot. Strikingly, even in the absence of joint erosions, marked alterations were found. Comparable differences were also observed between the patients with and without swollen and/or tender joints. Additionally, alterations were not strongly related to foot pain and disability, suggesting the capacity of the foot digitizer to detect early changes in foot structure.

CONCLUSION

The results highlight the impact of RA on foot structure, even in the absence of clinical signs of swelling or radiographic erosions. The foot digitizer offers a valuable tool to screen for such foot deformities before the presence of erosions.

Custom foot orthoses for rheumatoid arthritis: A systematic review

OBJECTIVE

To identify and critically appraise the evidence for the effectiveness of custom orthoses for the foot and ankle in rheumatoid arthritis.

METHODS

Studies were identified in appropriate electronic databases (from 1950 to March 2011). The search term "rheumatoid arthritis" with "foot" and "ankle" and related terms were used in conjunction with "orthoses" and synonyms. Included studies were quantitative longitudinal studies and included randomized controlled trials (RCTs), case-control trials, cohort studies, and case series studies. All outcome measures were investigated. Quality assessment was conducted using the Cochrane Collaboration criteria with additional criteria for sample population representativeness, quality of statistical analysis, and compliant intervention use and presence of cointerventions. Meta-analyses were conducted for outcome domains with multiple RCTs. Qualitative data synthesis was conducted for the remaining outcome domains. Levels of evidence were then assigned to each outcome measure.

RESULTS

The inclusion criteria were met by 17 studies. Two studies had high quality for internal validity and 3 studies had high quality for external validity. No study had high quality for both internal and external validity. Six outcome domains were identified. There was weak evidence for custom orthoses reducing pain and forefoot plantar pressures. Evidence was inconclusive for foot function, walking speed, gait parameters, and reducing hallux abductovalgus angle progression.

CONCLUSION

Custom orthoses may be beneficial in reducing pain and elevated forefoot plantar pressures in the rheumatoid foot and ankle. However, more definitive research is needed in this area.

Active foot synovitis in patients with rheumatoid arthritis: applying clinical criteria for disease activity and remission may result in underestimation of foot joint involvement

OBJECTIVE

To determine whether application of criteria for remission in rheumatoid arthritis (RA) may result in underestimation of foot joint involvement among patients in a clinic setting.

METHODS

RA patients (n = 123) were assessed at baseline and 6 months after commencement of a response-driven combination disease-modifying antirheumatic drug (DMARD) protocol. Remission was assessed using disease activity measures (the 28-joint Disease Activity Score using the erythrocyte sedimentation rate [DAS28-ESR], Simplified Disease Activity Index [SDAI], and Clinical Disease Activity Index [CDAI]) as well as Boolean-based criteria for remission (the 1981 American College of Rheumatology [ACR] preliminary criteria and the 2011 ACR/European League Against Rheumatism [EULAR] provisional criteria). The prevalence of foot synovitis and the mean swollen/tender foot joint count in RA patients meeting any of these remission criteria were estimated by hurdle (mixed distribution) regression.

RESULTS

In patients who received 6 months of combination DMARD treatment, application of the 1981 ACR criteria and the newly proposed 2011 ACR/EULAR criteria, each utilizing full joint counts (which includes assessment of the feet), classified the least number of patients as being in remission (8-10%), and evidence of foot synovitis was minimal among these patients. In contrast, ongoing foot synovitis was present in a substantial proportion of patients (>20%) meeting the 28-joint count criteria for remission, including the DAS28-ESR, SDAI, CDAI, and 2011 ACR/EULAR criteria (clinical practice setting or clinical trials). Furthermore, applying the 2011 ACR/EULAR composite remission criterion of a SDAI score ≤3.3 to define remission did not adequately capture the resolution of foot synovitis (i.e., residual foot involvement was still detected in a substantial proportion of patients classified as being in remission by this definition).

CONCLUSION

Although the DAS28-ESR, CDAI, and SDAI have been validated for assessment of remission in RA, this study shows that the performance of these 3 disease activity measures, which do not provide a direct assessment of the foot, in detecting foot synovitis is poor, in contrast to that of the 1981 ACR and 2011 ACR/EULAR remission criteria utilizing full joint counts. Thus, patients may be at risk of ongoing damage if treatment decisions are made solely on the basis of criteria that omit foot joint assessment.

Brief Report: to squeeze or not to squeeze, that is the question! Optimizing the disease activity score in 28 joints by adding the squeeze test of metatarsophalangeal joints in early rheumatoid arthritis

OBJECTIVE

To optimize use of the Disease Activity Score in 28 joints (DAS28) in early rheumatoid arthritis (RA) by adding the "squeeze test" of forefeet.

METHODS

The squeeze test is used to examine bilateral compression pain (BCP) across the metatarsophalangeal (MTP) joints. For this study, data for patients participating in the Treatment in the Rotterdam Early Arthritis Cohort study, an ongoing clinical trial that evaluates different induction therapies in patients with early RA, were randomly divided into 2 subsets. In subset 1 (149 patients and 819 disease activity assessments), the mathematical function of the DAS28-squeeze was constructed using a linear regression model with the DAS as the dependent variable and the DAS28 and squeeze test as the independent variables. A DAS28-BCP disease state was also constructed, in which DAS28 disease state categorizations were upgraded one state if the result of the squeeze test was positive. In subset 2 (153 patients and 754 assessments), concordance in disease states between the DAS28, DAS28-squeeze, and DAS28-BCP disease states was compared, using both the DAS and Boolean-defined remission criteria as reference.

RESULTS

Agreement between the DAS and the DAS28-squeeze (82%) was significantly higher than agreement between the DAS and the DAS28 (76%). When we assessed the group of patients who had arthritis of the forefeet only (22 patients and 46 assessments), overall agreement between the DAS and the DAS28 was 40%, while agreement between the DAS and the DAS28-squeeze was 59% and that between the DAS and the DAS28-BCP disease state was 65%. Furthermore, the specificities of the DAS28-squeeze and the DAS28-BCP (80% and 81%, respectively) were higher than that of the DAS28 (76%), while the sensitivities of the DAS28, DAS28-squeeze, and DAS28-BCP to identify true remission according to the Boolean criteria were 88%, 87%, and 81%, respectively.

CONCLUSION

Adding the squeeze test of forefeet to the DAS28 has value for dependably classifying the disease state in patients with early RA.

Transforming growth factor β 869C/T and interleukin 6 -174G/C polymorphisms relate to the severity and progression of bone-erosive damage detected by ultrasound in rheumatoid arthritis

Introduction

Single nucleotide polymorphisms (SNPs) of transforming growth factor β (TGF-β) and IL-6 genes (respectively, 869C/T and -174G/C) have been associated with radiographic severity of bone-erosive damage in patients with rheumatoid arthritis (RA). Musculoskeletal ultrasound (US) is more sensitive than radiography in detecting bone erosion. We analyzed the association between TGF-β 869C/T and IL-6 -174G/C SNPs and bone-erosive damage, evaluated by US, in a cohort of patients with severely active RA.

Methods

Seventy-seven patients were enrolled before beginning anti-TNF treatment. Disease activity was measured using the disease activity score in 28 joints, and the clinical response was evaluated according to the European League Against Rheumatism response criteria. Rheumatoid factor (RF) and anticitrullinated protein/peptide antibodies (ACPAs) were detected. The 869C/T TGF-β and -174G/C IL-6 SNPs were analyzed by PCR amplification. US was performed to assess the bone surfaces of metacarpophalengeal (MCP), proximal interphalangeal (PIP) and metatarsophalangeal (MTP) joints by obtaining multiplanar scans. According to the number of erosions per joint, a semiquantitative score ranging from 0 to 3 was calculated in each anatomical site to obtain a MCP total erosion score (TES), a PIP TES and a MTP TES, all ranging from 0 to 30, and a global patient TES calculated as the sum of these scores (range, 0 to 90).

Results

Patients carrying the TGF-β 869TT genotype showed a statistically significant lower MTP TES than those with the CC or CT genotype (mean MTP TES ± standard deviation for 869TT 6.3 ± 5.7 vs. 869CC/CT 11.7 ± 7.8; P = 0.011). Interestingly, patients with the TT genotype showed dichotomous behavior that was dependent on autoantibody status. In the presence of ACPAs and/or RF, the TT genotype was associated with lower erosion scores at all anatomical sites compared with the CC and CT genotypes. Conversely, the same 869TT patients showed higher erosion scores in the absence of ACPAs or RF.

Conclusions

In RA patients, TGF-β 869C/T SNPs could influence the bone-erosive damage as evaluated by US. The serological autoantibody status (ACPAs and RF) can modulate this interaction.

Use of conservative and surgical foot care in an inception cohort of patients with rheumatoid arthritis

Objectives. To describe conservative and surgical foot care in patients with RA in England and explore factors that predict the type of foot care received.

Methods. Use of podiatry and type of foot surgery were outcomes recorded in an inception cohort involving nine rheumatology centres that recruited patients with RA between 1986 and 1998 across England. Associations between patient-specific factors and service use were identified using univariate logistic regression analyses. The independence of these associations was then verified through multiple binary logistic regression modelling.

Results. Data were collected on 1237 patients with RA [66.9% females, mean (s.d.) age at disease onset = 54.36 (14.18) years, median DAS = 4.09 (1st quartile = 3.04, 3rd quartile = 5.26), median HAQ = 1 (0.50, 1.63)]. Interventions involving the feet in the cohort were low with only 364 (30%) out of 1218 receiving podiatry and 47 (4%) out of 1237 patients having surgery. At baseline, female gender, increasing age at onset, being RF positive and higher DAS scores were each independently associated with increased odds of seeing a podiatrist. Gender, age of onset and baseline DAS were independently associated with the odds of having foot surgery.

Conclusions. Despite the known high prevalence of foot pathologies in RA, only one-third of this cohort accessed podiatry. While older females were more likely to access podiatry care and younger patients surgery, the majority of the RA population did not access any foot care.

Remission in rheumatoid arthritis

With advancing therapeutic options, achieving a state of remission has become the treatment goal in rheumatoid arthritis. Agreeing on what constitutes remission and what measures should be used to assess disease activity has remained a challenge. Multiple remission criteria have been devised and modified, all with different strengths and limitations. A consensus definition of remission will need to be achieved if we are to be able to evaluate outcomes of clinical trials and establish treatment targets for practice. Remission defined as the complete absence of disease currently may not be a realistic therapeutic goal.

Looking through the 'window of opportunity': is there a new paradigm of podiatry care on the horizon in early rheumatoid arthritis?

Over the past decade there have been significant advances in the clinical understanding and care of rheumatoid arthritis (RA). Major paradigm changes include earlier disease detection and introduction of therapy, and 'tight control' of follow-up driven by regular measurement of disease activity parameters. The advent of tumour necrosis factor (TNF) inhibitors and other biologic therapies have further revolutionised care. Low disease state and remission with prevention of joint damage and irreversible disability are achievable therapeutic goals. Consequently new opportunities exist for all health professionals to contribute towards these advances. For podiatrists relevant issues range from greater awareness of current concepts including early referral guidelines through to the application of specialist skills to manage localised, residual disease activity and associated functional impairments. Here we describe a new paradigm of podiatry care in early RA. This is driven by current evidence that indicates that even in low disease activity states destruction of foot joints may be progressive and associated with accumulating disability. The paradigm parallels the medical model comprising early detection, targeted therapy, a new concept of tight control of foot arthritis, and disease monitoring.

'Podiatrists are experts on foot disorders: both patients and rheumatologists can profit from the involvement of a podiatrist'

- Korda and Balint, 2004 [1].