An evaluation of podiatry service use for people with inflammatory rheumatic diseases: a review of a rheumatology podiatry clinic in Aotearoa New Zealand

Inflammatory rheumatic diseases, including gout, psoriatic arthritis, rheumatoid arthritis, and systemic lupus erythematosus, are characterised by inflammation of joints and surrounding soft tissue, as well as extra-articular and systemic symptoms [1]. Foot and lower limb problems are significantly more prevalent in this population compared to people without inflammatory rheumatic diseases, with foot pain being the most common symptom reported [2] and a major determinant of lower limb disability [3, 4]. Compared to healthy individuals, people with inflammatory rheumatic diseases also present with reduced foot and ankle motion, muscle weakness, and a high prevalence of structural foot deformities [4‐6].

The needs of people with inflammatory rheumatic diseases are often complex and foot problems are frequently overlooked during routine assessments in general practice and rheumatology [7, 8]. A range of studies and international guidelines recognise the importance of podiatrists in the interdisciplinary management of people with inflammatory rheumatic diseases in order to relieve pain, maintain function and improve quality of life [9‐11]. These guidelines recommend the provision of podiatry services for assessment and periodic review of foot health needs, including appropriate footwear and orthoses for comfort, mobility and stability [12‐14]. Unfortunately, dedicated podiatry services directed towards people with inflammatory rheumatic diseases are scarce [15‐17], including in Aotearoa New Zealand [18], where 5.8% of older adults aged ≥ 65 years are living with rheumatoid arthritis, and an even higher 11.9% with gout (with Māori and Pacific peoples disproportionately affected by gout) [19]. A 2009 audit in Aotearoa New Zealand revealed that three quarters of people with rheumatoid arthritis who reported disabling foot pain, had not received a foot assessment, nor seen a podiatrist [18].

In support of the need for improved access to podiatry services for people with inflammatory rheumatic diseases, the podiatry school at Auckland University of Technology (AUT) established a Podiatric Rheumatology Clinic in 2010, which remains one of only two podiatry clinics in Aotearoa New Zealand providing dedicated services to people with inflammatory rheumatic diseases. The AUT Podiatric Rheumatology Clinic welcomes both adult and paediatric patients, including those with juvenile idiopathic arthritis. As a clinical teaching environment, the clinic offers a standard approach to service provision consistent with usual practice, where patients are assessed and treated by podiatry students under the supervision of highly experienced podiatric clinicians.

An important step in tailoring specific foot-care assessment and management approaches to people with inflammatory rheumatic diseases, is to improve understanding of the foot-care needs and current services provided to this population. This study aimed to evaluate podiatry service use for people with inflammatory rheumatic diseases who attended the AUT Podiatric Rheumatology Clinic between 2010 and 2021.

A total population sampling approach was used to identify all people with an inflammatory rheumatic disease who were coded as a “rheumatology patient” within the AUT Podiatry Clinic business practice software package (Gensolve Practice Manager™) from March 2010 through to the end of December 2021. The AUT Podiatric Rheumatology Clinic is part of a larger inter-disciplinary healthcare centre offering other podiatry services, as well as physiotherapy, occupational therapy, oral health, counselling, and psychotherapy. Referrals to the Podiatric Rheumatology Clinic are primarily from local rheumatologists and general practitioners, however, the Clinic also welcomes within-centre referrals and self-referrals. Depending on their foot-care needs, patients may attend a single appointment at the Podiatric Rheumatology Clinic, or attend regular ongoing appointments. Patients were included if they had a physician-confirmed diagnosis or self-reported physician diagnosis of at least one type of inflammatory rheumatic disease and attended one or more podiatry appointments. Patients were not included in the review if they had a diagnosis of osteoarthritis in the absence of another inflammatory rheumatic disease, or who were referred but did not attend an appointment at the clinic, or had an unknown or unconfirmed diagnosis.

Ethical approval was obtained from the Auckland University of Technology Ethics Committee (21/405). The need to obtain consent from patients for the use of their information, which was collected as part of usual clinical care, was waived by the Ethics Committee.

This is the first study focusing on podiatric service provision for people with inflammatory rheumatic diseases attending a specialist podiatric rheumatology clinic in Aotearoa New Zealand. The findings have shown that patients exhibit a wide range of foot problems, which often go beyond those they self-report. In addition, although education and general skin and/or nail care were the most common treatments provided to patients during regular follow-up appointments, most patients also received orthoses, footwear, padding and/or offloading at some point during their period of service provision.

Consistent with existing literature, this study has shown that people with inflammatory rheumatic diseases report a range of foot-related concerns, with foot pain and skin/nail problems among the most common, and neurovascular problems occurring less frequently [4, 7, 21‐23]. However, the foot problems identified from podiatric assessments often went beyond the concerns reported by patients, with the majority of patients also exhibiting clinical evidence of biomechanical, structural, and footwear-related problems. These findings clearly highlight the importance of thorough podiatric clinical assessments to identify all factors contributing to the patients concerns, as well as patient education surrounding the impact of inflammatory rheumatic diseases on foot and lower limb pain and disability.

Results from this study have also demonstrated the range of foot-care interventions provided to people with inflammatory rheumatic diseases. Consistent with current guidelines and expert recommendations [14, 24‐28], patients attending the AUT Podiatric Rheumatology Clinic received treatment of skin and nail problems, wound care, clinical padding, foot orthoses, and footwear prescription and advice. However, the most common intervention was foot-care education, provided during almost all appointments. Despite the absence of any formal published guidelines on education for rheumatology patients attending podiatry services [29, 30], foot-care education is recognised as a key intervention for people with inflammatory rheumatic diseases in improving patient knowledge and health outcomes [27, 31, 32]. In terms of overall service provision, the results from this study show promise in addressing the previously reported unmet need for provision of podiatric services to support people with inflammatory rheumatic diseases in Aotearoa New Zealand [18].

The current review also captured data relating to referrals, attendance and wait times. The majority of patients were referred from rheumatology services, with very few from other health providers, likely due to the paucity of specialist podiatric rheumatology clinics in Aotearoa New Zealand and the lack of awareness among potential referrers. In terms of attendance, a large proportion of patients referred to the AUT Podiatric Rheumatology Clinic did not attend an appointment. Existing research has highlighted a number of factors which may influence a patients decision to access foot-care, including a lack of patient awareness around the role of the podiatrist [33], perceived costs, as well as personal values and feeling that their feet are unimportant if they had been overlooked in clinical practice [7, 34, 35]. These barriers, which influence the patient’s decision to self-refer, suggest that patients should not be given the sole responsibility to seek podiatry services if they are to be delivered in an appropriate and timely manner [35]. Previous research has also highlighted that knowledge of the depth and value of podiatry practice by referring practitioners is lacking, and strategies that raise the profile of the profession, facilitate more streamlined pathways, and development of national clinical practice guidelines may improve uptake of podiatry services for patients with inflammatory rheumatic diseases [33, 36]. Finally, in reference to wait times, the relatively short wait times between referral and appointment observed in the current review are promising (median ~ 2 months). The majority of patients also attended regular four-monthly appointments which may support the importance of regular foot-care to prevent the development of new foot problems and address the changing concerns of the patient over time [14, 24‐28].

Māori and Pacific peoples were under-represented among patients attending the AUT Podiatric Rheumatology Clinic relative to the proportion of these ethnic groups with rheumatic diseases in Aotearoa New Zealand. A 2018 report by Arthritis New Zealand (Kaiponapona Aotearoa) revealed the prevalence of rheumatic diseases was 1.24 times higher in Māori compared with non-Māori [19]. The low proportion of Māori patients attending podiatry services in the current study may be related to the location of the clinic in north Auckland, which has a relatively low Māori population compared to other regions in Aotearoa New Zealand [37]. These findings reflect the need for improved access to specialist podiatric rheumatology services to reduce inequities, which address referrer attitudes and behaviours, barriers related to attending clinics, and continued cultural safety training for students and practitioners [38‐40]. Future work will evaluate how current service provision can be adapted to facilitate equitable access to podiatry services for patients with inflammatory rheumatic diseases across all ethnicity groups.

This study has some limitations. Firstly, although the student-led AUT Podiatric Rheumatology Clinic aims to offer a standard approach to service provision consistent with usual practice, appointment times are often slightly longer (~ 1 hour) which may allow for more in-depth assessments to be carried out compared to usual podiatric practice. Secondly, the retrospective nature of the current study meant data were extracted from clinical records that were not originally designed for research purposes and there is currently an absence of validated tools to categorise clinical record data based on service provision. However, the processes used to categorise this data have been explicitly outlined in the methods section to improve reproducibility. It should also be acknowledged that this review included data from 2020 through 2021 in which the Covid-19 pandemic and nationwide lockdowns would have influenced appointment numbers and time between appointments due to closure of the clinic. Finally, this review did not capture data related to the efficacy of podiatric services for people with inflammatory rheumatic diseases due to the absence of a standardised measure of treatment outcome used consistently across appointments. This will be the focus of future research.

In conclusion, this study has shown that people with inflammatory rheumatic diseases present with a wide range of foot problems that go beyond general skin/nail care and education to include footwear, orthoses, other padding/offloading devices, wound care, exercise prescription and referrals. The results have also shown that a specialist podiatric rheumatology clinic dedicated to people with inflammatory rheumatic diseases can provide services targeted towards these foot problems.