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

Do Dynamic Plantar Pressures Differ Based on Sonographic Evidence of Metatarsophalangeal Joint Synovitis in People With Rheumatoid Arthritis?

OBJECTIVE

The metatarsophalangeal joints (MTPJs) are the most common location for synovitis in people with rheumatoid arthritis (RA), yet their association with plantar foot pressures has received very little attention. This study aimed to determine whether plantar pressures differed based on sonographic evidence of MTPJ synovitis in people with RA.

METHOD

Ultrasound was used to assess synovitis (grey scale synovial hypertrophy and power Doppler signal) in MTPJs 1 to 5 using the combined EULAR/Outcome Measures in Rheumatology scoring system. Peak pressure (PP) and pressure time integrals (PTIs) were assessed during barefoot walking for seven plantar foot regions (heel, midfoot, first metatarsal, second metatarsal, third to fifth metatarsals, hallux, lesser toes). Mixed-effects linear regression was used to determine the difference in PP and PTI between MTPJs with none/minimal synovitis and MTPJs with moderate/severe synovitis.

RESULTS

Thirty-five participants with RA were included. Mean age was 66.3 years and mean disease duration was 22.2 years. Participants with sonographic evidence of moderate/severe synovitis at the first MTPJ had reduced PTI at the hallux compared with those with none/minimal synovitis at this joint (P = 0.039). Participants with moderate/severe synovitis at the second MTPJ and fourth MTPJ had reduced PP and reduced PTI at lesser toes compared with those with none/minimal synovitis in these joints (all P ≤ 0.048). No significant differences were observed for synovitis in other joints.

CONCLUSION

These findings may be suggestive of an inverse relationship between plantar pressure and soft tissue pathology, which is consistent with an offloading strategy and reduced use of the toes during propulsion.

What are the core recommendations for rheumatoid arthritis care? Systematic review of clinical practice guidelines

Systematic r eview to evaluate the quality of the clinical practice guidelines (CPG) for rheumatoid arthritis (RA) management and to provide a synthesis of high-quality CPG recommendations, highlighting areas of consistency, and inconsistency. Electronic searches of five databases and four online guideline repositories were performed. RA management CPGs were eligible for inclusion if they were written in English and published between January 2015 and February 2022; focused on adults ≥ 18 years of age; met the criteria of a CPG as defined by the Institute of Medicine; and were rated as high quality on the Appraisal of Guidelines for Research and Evaluation II instrument. RA CPGs were excluded if they required additional payment to access; only addressed recommendations for the system/organization of care and did not include interventional management recommendations; and/or included other arthritic conditions. Of 27 CPGs identified, 13 CPGs met eligibility criteria and were included. Non-pharmacological care should include patient education, patient-centered care, shared decision-making, exercise, orthoses, and a multi-disciplinary approach to care. Pharmacological care should include conventional synthetic disease modifying anti-rheumatic drugs (DMARDs), with methotrexate as the first-line choice. If monotherapy conventional synthetic DMARDs fail to achieve a treatment target, this should be followed by combination therapy conventional synthetic DMARDs (leflunomide, sulfasalazine, hydroxychloroquine), biologic DMARDS and targeted synthetic DMARDS. Management should also include monitoring, pre-treatment investigations and vaccinations, and screening for tuberculosis and hepatitis. Surgical care should be recommended if non-surgical care fails. This synthesis offers clear guidance of evidence-based RA care to healthcare providers. TRIAL REGISTRATION: The protocol for this review was registered with Open Science Framework ( https://doi.org/10.17605/OSF.IO/UB3Y7 ).

Whole-Body Macrophage Positron Emission Tomography Imaging for Disease Activity Assessment in Early Rheumatoid Arthritis

OBJECTIVE

To investigate the potential of whole-body positron emission tomography/computed tomography (PET/CT) with a macrophage tracer to image arthritis in patients with early rheumatoid arthritis (RA).

METHODS

Thirty-five previously untreated, clinically active patients with early RA underwent whole-body PET/CT scanning with the macrophage tracer (R)-[¹¹C]PK11195 in addition to clinical assessment (Disease Activity Score in 44 joints [DAS44]). Tracer uptake was assessed quantitatively as standardized uptake values (SUVs). In addition, 2 readers blinded to clinical assessment visually scored tracer uptake in joints. Clinical and PET variables were compared using Cohen , linear regression/correlation, and t tests, where appropriate.

RESULTS

All but 1 patient showed enhanced tracer uptake in at least 1 joint. Twelve percent of all joints (171/1470) were visually positive on the PET scan, most frequently the small joints in feet (40%) and hands (37%), followed by wrists (15%). Correlations of visual scores with clinical findings both at patient and joint levels were absent or weak. In contrast, average SUVs in the hands, feet, and whole body showed significant correlations with DAS44 scores, with the best correlation seen in the feet (R² = 0.29, P < 0.01).

CONCLUSION

Clinically active patients with early RA had increased joint uptake of a macrophage PET tracer, especially in the feet. Quantitative, but not visual PET measures of whole body and joint groups, particularly the feet, showed moderate and statistically significant correlations with clinical outcome.

Plantar pressure during gait: norm-referenced measurement for Brazilian healthy adults using the Footwork Pro® System

Abstract Introduction The measurement of plantar pressure is an important component in the evaluation of the locomotive system. However, the absence of norm-referenced measurement poses limitations to its use. Objective To verify the influence of gender on plantar pressure during gait in healthy adults and to propose norm-referenced measurement that may be used as a reference for monitoring. Methods The study included 353 healthy participants (158 females and 195 males), aged between 20 and 64 years, and with a normal foot posture. Using a pressure platform, the peak plantar pressure and pressure-time integrals were measured in three areas of the foot: forefoot, midfoot, and hindfoot. Results Both indicators of plantar pressure showed no significant differences between genders (p ≤ 0.05). Higher peak plantar pressure was found in the forefoot region, while a higher pressure-time integral was found in the hindfoot region. Percentile distribution values were made available for the data set of females and males. Conclusion The available norm-referenced measurement may be used to identify pathological gait parameters, monitor the efficacy of therapeutic interventions, and detect individuals in need of referral for a more sophisticated and detailed evaluation.

The effect of pre-fabricated insole on plantar pressure distribution in patients with rheumatoid arthritis

BACKGROUND

Foot deformities result in pain and changes in plantar pressure distribution in rheumatoid arthritis (RA) patients. Medical insoles are commonly prescribed for declining pain and modifying foot pressure distribution in these patients. The purpose of this study was to evaluate the effect of a pre-fabricated insole with metatarsal pad and medial longitudinal arch support on plantar pressure distribution in rheumatoid arthritis patients.

METHODS

Fifteen females with RA participated in this study. All patients received a pair of pre-fabricated insoles that were individually modified using metatarsal pads and medial longitudinal arch supports. Mean peak pressure (kPa), maximum force (N), and contact area (cm²) were calculated for the heel, midfoot, metatarsophalangeal joint, and toe regions using the Pedar-X system immediately and after a month follow-up.

FINDINGS

In the heel and metatarsophalangeal joint regions, maximum pressure and force showed a significant reduction in the follow-up assessment (p < 0.05). The comparison showed a significant increase in maximum pressure and force in the midfoot when participants walked with insole compared to without insole condition (p < 0.001).

INTERPRETATION

Using a pre-fabricated insole with an individually modified metatarsal pad and medial longitudinal arch support could alter rheumatoid arthritis patients' plantar pressures after one month of follow-up. This type of insole is simple and inexpensive and showed a significant effect on decreasing pressures under the metatarsal heads.

A qualitative study exploring the experiences and perceptions of patients with rheumatoid arthritis before and after wearing foot orthoses for 6 months

Foot pathology in people with rheumatoid arthritis (RA) can have a psychosocial impact, but interventions such as foot orthoses can reduce foot pain, improving physical activity and quality of life. A previous meta-analysis concluded that foot orthoses can relieve pain and disability and enhance patient's well-being. The aim of this study was to explore the experiences of people with RA, before and after wearing foot orthoses for 6 months. Data were collected through digital recordings of semi-structured interviews carried out before and after wearing foot orthoses for 6 months. A thematic analysis of the transcripts was used to identify themes. Six female participants with RA wore foot orthoses for 6 months in Spain. The mean disease duration was more than 10 years. The findings showed three key themes emerged from the data: (1) improvement in physical activity; (2) footwear… a tricky situation and (3) social implications of RA feet. It is concluded that patients reported that wearing foot orthoses can have a positive impact on physical activity and improve general wellness and quality of life. However, to achieve the potential positive benefits, people with RA also needed to wear suitable footwear (defined as footwear which accommodates both the foot and the insole while maintaining the fit and function of the shoe). Despite the positive impact of wearing orthoses, participants stated that complexities of finding suitable footwear acted as a blocker.

Clinical guidance for podiatrists in the management of foot problems in rheumatic disorders: evaluation of an educational programme for podiatrists using a mixed methods design

Background

Foot and ankle problems are common in rheumatic disorders and often lead to pain and limitations in functioning, affecting quality of life. There appears to be large variability in the management of foot problems in rheumatic disorders across podiatrists. To increase uniformity and quality of podiatry care for rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthritis (SpA), and gout a clinical protocol has been developed.

Research objectives

[1] to evaluate an educational programme to train podiatrists in the use of the protocol and [2] to explore barriers and facilitators for the use of the protocol in daily practice.

Method

This study used a mixed method design and included 32 podiatrists in the Netherlands. An educational programme was developed and provided to train the podiatrists in the use of the protocol. They thereafter received a digital questionnaire to evaluate the educational programme. Subsequently, podiatrists used the protocol for three months in their practice. Facilitators and barriers that they experienced in the use of the protocol were determined by a questionnaire. Semi-structured interviews were held to get more in-depth understanding.

Results

The mean satisfaction with the educational programme was 7.6 (SD 1.11), on a 11 point scale. Practical knowledge on joint palpation, programme variation and the use of practice cases were valued most. The protocol appeared to provide support in the diagnosis, treatment and evaluation of foot problems in rheumatic disorders and the treatment recommendations were clear and understandable. The main barrier for use of the protocol was time. The protocol has not yet been implemented in the electronic patient file, which makes it more time consuming. Other experienced barriers were the reimbursement for the treatment and financial compensation.

Conclusions

The educational programme concerning the clinical protocol for foot problems in rheumatic disorders appears to be helpful for podiatrists. Podiatrists perceived the protocol as being supportive during patient management. Barriers for use of the protocol were identified and should be addressed prior to large scale implementation. Whether the protocol is also beneficial for patients, needs to be determined in future research.

Intervention study of a foot-care programme enhancing knowledge and practice among nurses and care workers at in-home service providers

Aim

To evaluate the foot-care educational programme for nurses and care workers at in-home service providers.

Design

A non-randomized controlled study with random cluster sampling method.

Methods

Study participants were nurses and care workers of 21 in-home service providers, including home-visit nursing and care providers, 1-day care service centres or care centres with rehabilitation programme in Japan. Foot-care programme with foot-care tools as a package or standard care comprising 3-5 sessions over 2 months was provided to 110 participants (87 were on analysis). The outcomes were changes in foot-care knowledge and scores in pre-post interventions. Data were analysed with descriptive statistics, t test, logistic regression analysis and ANCOVA.

Results

Before adjusting for background, total scores of knowledge and practice categories were higher than the baseline in the intervention group (43 participants) compared with the control group (44 participants). After background correction due to potential bias of non-random cluster sampling, significant between group differences were observed in mean score changes in skin and consultation subscales of the practice category.

Do ankle, hindfoot, and heel ultrasound findings predict the symptomatology and quality of life in rheumatoid arthritis patients?

Objectives: To evaluate the ankle, hindfoot, and heel changes (determined by physical examination, ultrasound and baropodometry) in patients with rheumatoid arthritis, to compare the findings with healthy subjects, and to analyze if these findings are associated with ankle pain and could affect the quality of life. Methods: We enrolled 35 rheumatoid arthritis patients and 35 healthy controls, and evaluated their ankles (tibiotalar joints, tendons), hindfeet (talonavicular, subtalar joints) and heels using clinical examination, DAS28-CRP, RAPID3 for the evaluation of functional status, quality of life in rheumatoid arthritis questionnaire, ultrasound, and baropodometry. Results: The ultrasound inter-observer agreement was good for the subtalar joint, and very good for the other structures. Flat foot was identified in 50% of feet in rheumatoid arthritis patients, with 83.8% having concomitant hindfoot valgus and less subtalar joint synovitis visible from the lateral approach (32.4% vs 55.6%, p = 0.041). The body mass index, RAPID3 and subtalar synovitis were independent predictors for the symptomatic ankle (all p <0.05). Midfoot and heel plantar pressures were higher in rheumatoid arthritis patients compared to healthy controls, but when subtalar synovitis was present, the pressures decreased (avoidance of heel support). Poor quality of life in rheumatoid arthritis patients was independently predicted by DAS28-CRP, RAPID3, disease stage, hindfoot valgus, tibiotalar and subtalar synovitis, tendon pathology, Achilles tendon enthesophytes, calcaneal erosions, plantar fasciitis, and perifasciitis (all p <0.05). Conclusion: The quality of life of rheumatoid arthritis patients is significantly affected by ankle and hindfoot pathology (inflammatory modifications, but also degenerative findings and deformities). Ultrasound scanning is an important tool in the evaluation of inflammatory and degenerative lesions in these regions, and their early detection might contribute to a better therapeutic management in these patients.

Objectives: To evaluate the ankle, hindfoot, and heel changes (determined by physical examination, ultrasound and baropodometry) in patients with rheumatoid arthritis, to compare the findings with healthy subjects, and to analyze if these findings are associated with ankle pain and could affect the quality of life. Methods: We enrolled 35 rheumatoid arthritis patients and 35 healthy controls, and evaluated their ankles (tibiotalar joints, tendons), hindfeet (talonavicular, subtalar joints) and heels using clinical examination, DAS28-CRP, RAPID3 for the evaluation of functional status, quality of life in rheumatoid arthritis questionnaire, ultrasound, and baropodometry. Results: The ultrasound inter-observer agreement was good for the subtalar joint, and very good for the other structures. Flat foot was identified in 50% of feet in rheumatoid arthritis patients, with 83.8% having concomitant hindfoot valgus and less subtalar joint synovitis visible from the lateral approach (32.4% vs 55.6%, p = 0.041). The body mass index, RAPID3 and subtalar synovitis were independent predictors for the symptomatic ankle (all p <0.05). Midfoot and heel plantar pressures were higher in rheumatoid arthritis patients compared to healthy controls, but when subtalar synovitis was present, the pressures decreased (avoidance of heel support). Poor quality of life in rheumatoid arthritis patients was independently predicted by DAS28-CRP, RAPID3, disease stage, hindfoot valgus, tibiotalar and subtalar synovitis, tendon pathology, Achilles tendon enthesophytes, calcaneal erosions, plantar fasciitis, and perifasciitis (all p <0.05). Conclusion: The quality of life of rheumatoid arthritis patients is significantly affected by ankle and hindfoot pathology (inflammatory modifications, but also degenerative findings and deformities). Ultrasound scanning is an important tool in the evaluation of inflammatory and degenerative lesions in these regions, and their early detection might contribute to a better therapeutic management in these patients.

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.

Systematic review on the comparative effectiveness of foot orthoses in patients with rheumatoid arthritis

Background

Foot orthoses (FOs) are prescribed as an important conservative treatment option in patients with foot problems related to rheumatoid arthritis. However, a broad variation in FOs is used, both in clinical practice and in research. To date, there is no overview on the outcomes of the treatment with different kinds of FOs in patients with rheumatoid arthritis and a specific foot problem. The objectives of the present study were to summarize the comparative effectiveness of FOs in the treatment of various foot problems in patients with rheumatoid arthritis, on the primary outcomes foot function and foot pain, and the secondary outcomes physical functioning, health related quality of life, compliance, adverse events, the costs of FOs and patient satisfaction.

Methods

Studies comparing different kinds of FOs, with a presumed therapeutic effect, in the treatment of foot problems related to rheumatoid arthritis were included. A literature search was conducted in The Cochrane Central Registry for Controlled Trials (CENTRAL), PubMed, EMBASE and PEDro up to May 18th, 2018. Data was meta-analyzed, when this was not possible qualitative data analysis was performed.

Results

Ten studies were identified, with a total number of 235 patients. These studies made a comparison between different materials used (soft versus semi-rigid), types of FOs (custom-made versus ready-made; total-contact versus non-total contact), or modifications applied (metatarsal bars versus domes). Also, different techniques to construct custom-made FOs were compared (standard custom-molding techniques versus more sophisticated techniques). A medium effect for (immediate) reduction of forefoot plantar pressure was found in favor of treatment with soft FOs compared to semi-rigid FOs (SMD 0.60, 95% CI 0.07-1.14; P = 0.03; 28 participants). Other comparisons between FOs resulted in non-significant effects or inconclusive evidence for one kind of FOs over the other.

Conclusions

Foot orthoses made of soft materials may lead to more (immediate) forefoot plantar pressure reduction compared to foot orthoses constructed of semi-rigid materials. Definitive high quality RCTs, with adequate sample sizes and long-term follow-up, are needed to investigate the comparative (cost-) effectiveness of different kinds of foot orthoses for the treatment of foot problems related to rheumatoid arthritis.