Identifying patient-reported outcomes in rheumatoid arthritis: the impact of foot symptoms on self-perceived quality of life

Static Foot Disturbances and the Quality of Life of Older Person with Rheumatoid Arthritis

Disturbed static foot function is one of the main causes of impaired quality of life, which may be related to the frailty syndrome of older adult patients with Rheumatoid Arthitis (RA). The aim of the study was to evaluate the relationship between parameters of static foot function disturbances and quality of life of older adult patients with RA. The study was performed among 102 patients with RA diagnosed according to the American College of Rheumatology (ACR) and EULAR 2010 criteria. Patients were divided into four subgroups depending on radiological evaluation according to the Steinbrocker classification. Plantoconturography examination was conducted using a podoscope with a 3D scanner and software for computer foot examination CQ ST2K. Quality of life of patients with RA was evaluated using the Arthritis Impact Measurement Scales-2 (AIMS-2). A statistically significant relationship between AIMS-2 and parameters of static foot function disturbances was observed. The study revealed correlations between parameters of disturbed static foot function and RA severity in comparison to disease duration. Our results indicate a relationship between static foot function disturbances and quality of life of patients with RA, not only in the area of physical activity, but also in the social an emotional domain. Study results indicate that plantoconturography and assessment of quality of life using AIMS-2 could be useful as a diagnostic and prognostic tool in RA.

Self-assessed foot health in older people with rheumatoid arthritis-A cross-sectional study

BACKGROUND

Foot and ankle problems are especially common in patients with RA, causing significant disability and limitation in daily activities. Previous studies have mainly focussed on foot problems in the adult population whilst the evidence of foot health in the older population is scarce.

OBJECTIVES

The aim of the study was to analyse self-assessed foot health and associated factors in older people with rheumatoid arthritis (RA).

METHODS

The study applied a descriptive cross-sectional survey design and recruited older people with RA from the member register of one patient association. We collected the data in January 2019 with the Self-administered Foot Health Assessment Instrument, and sociodemographic and foot-related background questions and analysed the data with descriptive and inferential statistics.

RESULTS

Older people with RA had many self-reported foot problems. The most common problems were foot pain, dry skin and thickened toenails. In addition, structural deformities of the foot were prevalent. The level of foot health associated with the amount of daily walking or standing, and using walking or running shoes outdoors. Individuals who had consulted a physician due to their foot problems had more structural deformities in the foot. Foot problems limited their ability to perform daily activities.

CONCLUSIONS

This study demonstrates that older people with RA not only live with a long-term health condition, but they also live with complex foot problems. Older people with RA need healthcare services due to their foot problems. There is a need to develop and implement care practices to alleviate foot pain and support and promote foot health and functional ability in older people with RA.

IMPLICATION FOR PRACTICE

Understanding the nature and consequences of foot problems in older people with RA allows healthcare professionals to perform more accurate clinical foot evaluations and develop effective interventions to prevent further foot problems.

Outcomes and potential mechanism of a protocol to optimize foot orthoses in patients with rheumatoid arthritis

Background

Foot problems are highly prevalent in patients with rheumatoid arthritis. Treatment of foot problems related to rheumatoid arthritis often consists of custom made foot orthoses. One of the assumed working mechanisms of foot orthoses is redistribution of plantar pressure by creating a larger weight bearing area. Overall, the reported treatment effect of foot orthoses on foot pain in rheumatoid arthritis is small to medium. Therefore, we developed a foot orthoses optimization protocol for evaluation and adaptation of foot orthoses by using the feedback of in-shoe plantar pressure measurements. The objectives of the present study were: 1) to evaluate the 3-months outcomes of foot orthoses developed according to the protocol on pain, physical functioning and forefoot plantar pressure in patients with foot problems related to rheumatoid arthritis, and 2) to determine the relationship between change in forefoot plantar pressure and change in pain and physical functioning.

Methods

Forty-five patients with foot problems related to rheumatoid arthritis were included and received foot orthoses developed according to the protocol. Outcome measures were assessed at baseline and after three months of wearing foot orthoses in 38 patients. Change scores and effect sizes (ES) were calculated for pain, physical functioning and plantar pressure. In a subgroup of patients with combined forefoot pain and high plantar pressure, the relationship between change in plantar pressure and change in pain and physical functioning was analyzed.

Results

In the total group of 38 patients, statistically significant changes in pain (ES 0.69), physical functioning (ES 0.82) and forefoot plantar pressure (ES 0.35) were found. In the subgroup (n = 23) no statistically significant relationships were found between change in plantar pressure and change in pain or physical functioning.

Conclusion

Foot orthoses developed according to a protocol for improving the plantar pressure redistribution properties lead to medium to large improvements in pain and physical functioning. The hypothesis that more pressure reduction would lead to better clinical outcomes could not be proven.

Relationship Between Pain and Sedentary Behavior in Rheumatoid Arthritis Patients: A Cross-Sectional Study

OBJECTIVE

Despite the known benefits of physical activity, high numbers of individuals with rheumatoid arthritis (RA) remain physically inactive and sedentary. Little is known about the determinants of sedentary behavior (SB) in RA. This cross-sectional study was undertaken to examine a range of pain characteristics and RA-related symptoms and their relationship with objectively measured SB.

METHODS

In total, 76 adults with RA wore an activPAL4 accelerometer (PAL Technologies) over a 7-day period. Pain characteristics (pain intensity, painful joint count, nonarticular pain), fatigue, sleep, depression, anxiety, and disease activity were assessed. Analyses were first conducted to evaluate correlations with sedentary time. The independent contribution of pain characteristics to variation in SB was analyzed with multivariable linear regression (adjusted for demographic data and disease activity).

RESULTS

Participants with valid accelerometer data (n = 72) spent a mean ± SD of 533.7 ± 100.1 minutes/day in SB. Positive associations with daily SB were found for pain intensity (r = 0.31, P < 0.01) and number of painful joints (r = 0.24, P < 0.05) but not nonarticular pain. In multivariable analyses, pain characteristics were not independently associated with SB. Analyses indicated that disease activity had an indirect association with SB mediated by pain intensity. Other correlates of daily SB included anxiety and depression but not fatigue or sleep.

CONCLUSION

Results suggest that while pain and other RA-related factors do play a role in SB, they do not appear to have a significant influence after accounting for other variables. Future research should investigate SB and the role of factors unrelated to the symptoms of RA.

Foot Barriers in Patients With Early Rheumatoid Arthritis: An Interview Study Among Swedish Women and Men

OBJECTIVE

Foot impairments are related to reduced mobility and participation restrictions in daily activities in patients with established rheumatoid arthritis (RA). The new biologic medications are effective and reduce disease activity, but not disability to the same extent. Foot impairments are assumed to be related to participation restrictions also in patients with early RA, diagnosed after the introduction of biologic medications. Knowledge of foot impairments needs to be explored further after the introduction of biologic disease-modifying antirheumatic drugs (bDMARDs). The aim of this study was to explore the patients' perspective of foot impairments related to early RA.

METHODS

The sample included 59 patients (ages 20-63 years) who were interviewed about participation dilemmas in daily life using the critical incident technique. The interviews were audio-recorded and transcribed. Data related to foot impairments were extracted and analyzed thematically. A research partner validated the analysis.

RESULTS

Patients with early RA described a variety of participation restrictions related to foot impairments: foot hindrances in domestic life, foot impairments influencing work, leisure activities restricted by one's feet, struggling to be mobile, and foot impairments as an early sign of rheumatic disease.

CONCLUSION

There is a need to focus on foot impairments related to early RA, and for health care professionals to understand these signs. A suggestion for future research is to conduct a longitudinal followup of foot impairment related to medication, disease activity, and disability in patients diagnosed after the introduction of bDMARDs.

Sensory disturbance and polyneuropathy in rheumatoid arthritis patients with foot deformity

INTRODUCTION

Our aim in this study was to present the results of sensory evaluation tests and electrophysiological evaluations in rheumatoid arthritis (RA) patients with foot deformity and to determine their relation with general health status and lower extremity functionality.

MATERIALS AND METHODS

Fifty-one patients with RA diagnosis and foot deformity were included in the study. Demographic and disease characteristics of the patients were recorded, and a detailed neurological examination was performed. Superficial sensation, pain, heat, vibration, and two-point discrimination sensation were evaluated in each foot, and their sum was used to determine the sensory deficits index (SDI) of 0-10. The presence of polyneuropathy was evaluated with electrophysiological methods. The Health Assessment Questionnaire and mobility and walking subscales of the Arthritis Impact Measurement Scales-2 were used to assess general health status and lower extremity functionality, respectively. According to the sensory examination and electromyography results, patients were compared in terms of their general health status and lower extremity functional status.

RESULTS

Sensory disturbance was detected in 39 patients (74%) during the examination; however, 27 patients (52.9%) had polyneuropathy determined electrophysiologically. In patients with sensory deficits, statistically significant deterioration was detected in general health and foot functionality, including mobility and walking, when compared to patients with a normal sensory evaluation.

CONCLUSIONS

Even in the presence of normal electrophysiological tests, sensory dysfunction alone seems to be associated with severe disability in general health status and foot functionality when compared to patients with a normal sensory examination.

In-shoe plantar pressure measurements for the evaluation and adaptation of foot orthoses in patients with rheumatoid arthritis: A proof of concept study

OBJECTIVES

Improving foot orthoses (FOs) in patients with rheumatoid arthritis (RA) by using in-shoe plantar pressure measurements seems promising. The objectives of this study were to evaluate (1) the outcome on plantar pressure distribution of FOs that were adapted using in-shoe plantar pressure measurements according to a protocol and (2) the protocol feasibility.

METHODS

Forty-five RA patients with foot problems were included in this observational proof-of concept study. FOs were custom-made by a podiatrist according to usual care. Regions of Interest (ROIs) for plantar pressure reduction were selected. According to a protocol, usual care FOs were evaluated using in-shoe plantar pressure measurements and, if necessary, adapted. Plantar pressure-time integrals at the ROIs were compared between the following conditions: (1) no-FO versus usual care FO and (2) usual care FO versus adapted FO. Semi-structured interviews were held with patients and podiatrists to evaluate the feasibility of the protocol.

RESULTS

Adapted FOs were developed in 70% of the patients. In these patients, usual care FOs showed a mean 9% reduction in pressure-time integral at forefoot ROIs compared to no-FOs (p=0.01). FO adaptation led to an additional mean 3% reduction in pressure-time integral (p=0.05). The protocol was considered feasible by patients. Podiatrists considered the protocol more useful to achieve individual rather than general treatment goals. A final protocol was proposed.

CONCLUSIONS

Using in-shoe plantar pressure measurements for adapting foot orthoses for patients with RA leads to a small additional plantar pressure reduction in the forefoot. Further research on the clinical relevance of this outcome is required.

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.

Prevalence and microbiological characteristics of clinically infected foot-ulcers in patients with rheumatoid arthritis: a retrospective exploratory study

BACKGROUND

The prevalence of foot ulcers in patients with rheumatoid arthritis (RA) has been reported at almost 10 %. These foot ulcers often occur at multiple sites and are reoccurring, with the potential risk of infection increased due to RA diagnosis and disease modifying medications. The objective of this study was to estimate the prevalence of clinical infection in foot-ulcers of patients with RA; describe the microbiological characteristics and investigate risk factors.

METHODS

Retrospective clinical data was collected for all patients attending a rheumatology foot ulcer clinic between 1st May 2012 and 1st May 2013: wound swab data was collected from those with clinical infection.

RESULTS

Twenty-eight patients with RA and foot-ulcers were identified; eight of these patients had clinical infection and wound swabs taken (29 %). Of these eight patients there were equal men and women, with median age 74 years, and average disease duration 22 years. Cardiovascular disease/peripheral-vascular disease (CVD/PVD) were reported in six patients, diabetes in two patients. Six patients were treated with disease-modifying anti-rheumatic drugs (DMARDs); three were on biologic medications and two on steroids. Five wound swabs cultured skin flora, one staphylococcus aureus, one had no growth after culture; and one was rejected due to labelling error.

CONCLUSION

Almost a third of people with RA and foot ulcers attending clinic over one year had clinical infection, however microbiological analysis failed to isolate pathogens in six of seven wound swabs. This may be due to inaccurate diagnosis of ulcer infection or to issues with sampling, collection, transport, analysis or reporting. There was insufficient data to relate risk of clinical infection with risk factors. Further research is required to identify the most appropriate techniques for infection diagnosis, wound sampling and processing.

TRIAL REGISTRATION

Ethical approval was obtained from University of Leeds, Faculty of Medicine and Health (Reference number: SHREC/RP/349).

Patient Expectations and Perceptions of Goal-setting Strategies for Disease Management in Rheumatoid Arthritis

OBJECTIVE

To identify how patients perceive the broad effect of active rheumatoid arthritis (RA) on their daily lives and indicate how RA disease management could benefit from the inclusion of individual goal-setting strategies.

METHODS

Two multinational surveys were completed by patients with RA. The "Good Days Fast" survey was conducted to explore the effect of disease on the daily lives and relationships of women with RA. The "Getting to Your Destination Faster" survey examined RA patients' treatment expectations and goal-setting practices.

RESULTS

Respondents from all countries agreed that RA had a substantial negative effect on many aspects of their lives (work productivity, daily routines, participation in social and leisure activities) and emotional well-being (loss of self-confidence, feelings of detachment, isolation). Daily pain was a paramount issue, and being pain- and fatigue-free was considered the main indicator of a "good day." Setting personal, social, and treatment goals, as well as monitoring disease progress to achieve these, was considered very beneficial by patients with RA, but discussion of treatment goals seldom appeared to be a part of medical appointments.

CONCLUSION

Many patients with RA feel unable to communicate their disease burden and treatment goals, which are critically important to them, to their healthcare provider (HCP). Insights gained from these 2 surveys should help to guide patients and HCP to better focus upon mutually defined goals for continued improvement of management and achievement of optimal care in RA.

Perceived barriers to the management of foot health in patients with rheumatic conditions

BACKGROUND

Rheumatic conditions can have a significant impact on the feet and requires effective management. Podiatric involvement in the management of rheumatic conditions has previously been found to be inadequate in a hospital-setting and no study has examined current trends across New Zealand. The aim was to evaluate the perceived barriers of New Zealand podiatrists in the management of rheumatic conditions.

METHODS

A cross-sectional observational design using a web-based survey. The self-administered survey, comprising of thirteen questions, was made available to podiatrists currently practicing in New Zealand.

RESULTS

Fifty-six podiatrists responded and the results demonstrated poor integration of podiatrists into multidisciplinary teams caring for patients with arthritic conditions in New Zealand. Dedicated clinical sessions were seldom offered (16%) and few podiatrists reported being part of an established multidisciplinary team (16%). A poor uptake of clinical guidelines was reported (27%) with limited use of patient reported outcome measures (39%). The majority of podiatrists expressed an interest in professional development for the podiatric management of arthritic conditions (95%). All surveyed podiatrists (100%) agreed that there should be nationally developed clinical guidelines for foot care relating to arthritis.

CONCLUSIONS

The results suggest that there are barriers in the involvement of podiatrists in the management of people with rheumatic conditions in New Zealand. Future studies may provide an in-depth exploration into these findings to identify and provide solutions to overcome potential barriers.

Guidelines for the management of people with foot health problems related to rheumatoid arthritis: a survey of their use in podiatry practice

Background

In the last decade there has been a significant expansion in the body of knowledge on the effects of rheumatoid arthritis (RA) on the foot and the management of these problems. Aligned with this has been the development of specialist clinical roles for podiatrists. However, despite being recommended by national guidelines, specialist podiatrists are scarce. In order to inform non-specialist podiatrists of the appropriate interventions for these foot problems, management guidelines have been developed and disseminated by a group of specialist podiatrists. The aim of this survey was to investigate the use of these guidelines in clinical practice.

Method

Following ethical approval an online questionnaire survey was carried out. The questions were formulated from a focus group and comprised fixed response and open response questions. The survey underwent cognitive testing with two podiatrists before being finalised. An inductive approach using thematic analysis was used with the qualitative data.

Results

245 questionnaires were completed (128–non-specialist working in the private sector, 101 non–specialists working in the NHS and 16 specialist podiatrists). Overall, 97% of the non-specialists (n = 222) had not heard of the guidelines. The non-specialists identified other influences on their management of people with RA, such as their undergraduate training and professional body branch meetings. Three main themes emerged from the qualitative data: (i) the benefits of the foot health management guidelines, (ii) the barriers to the use of guidelines generally and (iii) the features of useable clinical guidelines.

Conclusions

This study has revealed some crucial information about podiatrists’ level of engagement with the foot health management guidelines and the use of guidelines in general. Specifically, the non-specialist podiatrists were less likely to use the foot health management guidelines than the specialist podiatrists. The positive aspects were that for the specialist practitioners, the guidelines helped them to identify their professional development needs and for the few non-specialists that did use them, they enabled appropriate referral to the rheumatology team for foot health management. The barriers to their use included a lack of understanding of the risk associated with managing people with RA and that guidelines can be too long and detailed for use in clinical practice. Suggestions are made for improving the implementation of foot health guidelines.

[Presurgical and postsurgical orthotic management of the rheumatoid foot]

Foot complaints remain frequent in patients with rheumatoid arthritis (RA) even in the era of biological anti-rheumatic drugs. Orthotic management of rheumatoid foot disorders is able to improve mobility and thus the quality of life in RA patients. This article highlights the preoperative and postoperative orthotic management of the rheumatoid arthritic foot.