Clinical audit of foot problems in patients with rheumatoid arthritis treated at Counties Manukau District Health Board, Auckland, New Zealand

Rheumatoid arthritis (RA) is the most common type of inflammatory arthritis [1]. The prevalence rate of RA in New Zealand has been reported to be between 0.79–2.6% [2, 3]. When untreated, the disease can progress rapidly, causing swelling and damage to cartilage and bone around the joints. Any joint may be affected, but hands, wrists and feet are most often involved [4].

The main symptoms of RA are severe pain, stiffness, fatigue and loss of mobility. 42% of RA patients are registered disabled within 3 yrs of diagnosis [2]. 80% are moderately to severely disabled within 20 yrs. At diagnosis, 16% of RA patients may have foot joint involvement [5] increasing to 90% as disease duration increases [5, 6]. This can lead to joint instability, difficulties in walking and limitation in functional ability that restricts activities of daily living [6]. The talo-navicular joint is the most commonly affected; subtalar joint involvement shows a similar pattern, with an increase of 25% between 5–10 years of duration [7]. Deformity of the tarsal joints and forefoot also occurs with disease progression [8].

Williams and Bowden [9] reported that the evidence base for dedicated podiatry as part of multidisciplinary foot clinics in diabetes is well established, but that this has yet to be achieved for rheumatology services [10]. However, the role of the podiatrist in the rheumatology team is becoming recognised as a vital component in the integrated care given to patients by the multidisciplinary team [11, 12]. Increasingly consultants and their teams are requesting specialist foot care services and it is suggested that the podiatrist is a key practitioner in the management of patients with musculoskeletal disease [11‐13]. It has been recommended that patients should understand the role and have access to a podiatrist [9]. The podiatrist's role is to identify, diagnose and treat disorders, diseases and deformities of the feet and legs and implement appropriate and timely care. Additionally, podiatrists also monitor foot health status, provide education and support in enabling behaviour change in lifestyle, and may be the only health-care professional that the patient sees on a regular basis. Therefore, they may arguably act as gatekeepers to other members of the multi-disciplinary team. This may be provided directly by a podiatrist or in association with other healthcare team members as required by the individual's foot problems [4].

The goal of the podiatry element of rheumatology care is to reduce foot-related pain, maintain/improve foot function and thus mobility, while protecting skin and other tissues from damage [4]

Despite this recognition, it is generally perceived that access to podiatry services for patients with rheumatic diseases appears to be varied and in some instances absent, especially in New Zealand. Podiatrists have a prominent role to play in symptom relief and improving quality of life because involvement of the feet, even to a mild degree, is a significant marker for impaired mobility, functional incapacity and negative psychosocial impact. Foot pathology contributes to difficulty with walking in about 75% of people with RA, and is the main or only cause of walking difficulty in 25% [1]. In the foot, joint pain and stiffness is the most common initial presentation, but a range of other features, including tenosynovitis, nodule formation and tarsal tunnel syndrome may also present, reflecting widespread soft-tissue involvement [13, 14].

Based upon the Arthritis and Musculoskeletal Alliance (ARMA) Standards of Care for People with Foot Health Problems and Inflammatory Arthritis [15] the purpose of this audit is to provide a benchmark by which podiatric service standards may be evaluated by all stakeholders. Therefore, the aim of this study is to identify the nature of foot problems experienced by patients attending rheumatology outpatient clinics at Counties Manukau District Health Board (CMDHB) and to ascertain the availability of podiatric services for these patients.

The purpose of this study was to undertake a clinical audit evaluating current RA foot care services in Counties Manukau. Overall, this study demonstrates that in this particular outpatient clinic, poor foot health and foot pain is highly prevalent in patients with rheumatic diseases. Over 85% of patients with RA had foot involvement ranging from callus, corns and lesser toe deformities. The study also demonstrated moderate impairment and limited activity using the Leeds Foot Impact Scale [12] suggesting the majority of patients suffer with long-term disability from this chronic condition.

The problem of footwear was highlighted in the audit. The majority of patients were observed wearing footwear that could be described as inappropriate for those patients with severe pain and disability and included sandals, mules and jandals. The lack of support mechanisms, cushioning and protection of toe regions may contribute to pain and disability.

The current clinical audit demonstrated 16% of RA patients presented with diabetes suggesting that patients with autoimmune disorders, and/or taking medication that compromises the immune system should be considered at risk of infection and foot ulceration, due to a lack of protection, especially on the plantar surface of the feet. Likewise, patients with micro-vascular and/or large vessel disease and foot deformity are also at risk of foot trauma, ulceration and subsequent infection [9]. The use of podiatrists and management programmes that includes advice of foot health education, appropriate footwear and prescription of foot orthoses is essential if we are to reduce the impact of foot problems in this patient group.

The results from the current audit are similar to UK audits [3, 9]. Recent reports from the UK recommend the need for more consistent provision of specialist care for patients with RA and better implementation of guidance and best practice [4, 21]. However, there is no similar data or recommendations for New Zealand, and there are no previous studies of foot problems in New Zealand patients with rheumatic diseases.

The results of this study support the case for a specialist podiatrist to manage patients with rheumatic diseases in this locality, whatever the patient's age or stage of disease. This audit recommends that in order to identify patients with foot problems, their consultant or specialist nurse should question patients about their feet. If foot problems are identified, a referral to the specialist podiatrist should be made. Patients with disabling foot pain, or who are at risk of foot ulceration, should receive priority foot care [9, 22]. Foot orthoses should be considered for patients recently diagnosed with RA as this intervention has been demonstrated to reduce pain and the effects of abnormal joint function in the foot [23].

The current audit demonstrated that RA patients reported podiatry was "very useful". However, patients perception of the term podiatry was related only to toenail cutting, and corn reduction rather than for structural modifications. The role of the podiatrist within rheumatology involves a range of different assessments and interventions [4]. An assessment of the lower limbs may include the skin, vascular and neurological systems, the musculoskeletal structures and walking. Specialist prescription footwear should also be available for patients who cannot fit into appropriate retail footwear and in this domain; both podiatrists and orthotists should collaborate to achieve the optimal clinical outcome [9]. Working with surgeons, in relation to appropriateness for foot surgery, should also be considered, as this option is often overlooked by podiatrists. This study demonstrates that there is an unmet need for specialist podiatry in patients attending this particular rheumatology outpatient clinic. A mechanism should be in place whereby everyone with a diagnosis of inflammatory arthritis receives a foot examination within three months of diagnosis [16].

Patients with RA should be provided with information and education to enable them to recognise the signs of these variations and understand what to do if variations occur. Increased systemic disease activity can accelerate changes in foot pathology so consideration must be taken of local as well as systemic factors. A recent study undertaken in the UK using a self-management foot care programme for 30 patients with RA demonstrated that just over 50% of patients were physically able to undertake some aspects of self-managed foot care, including nail clipping and filing, callus filing and daily hygiene and inspection [13]. A clinical audit of 139 rheumatoid patients undertaken in the UK reported that poor foot health and foot pain as being common in patients with rheumatic diseases [9]. The authors highlighted that the lack of foot care could lead to reduction in mobility and in some cases serious complications and recommended that a specialist and dedicated foot care service needs to be provided for these patients [9].

The current study has highlighted patients with RA have an increased need for a range of basic foot care services. There is evidence from the current literature that early intervention for existing or potential foot problems can improve long-term outcomes. Baseline foot examination can identify people with existing or imminent needs and provide a comparator for assessment. Regular assessments that document the rate of structural change can aid treatment decisions and improves outcomes. An annual musculoskeletal, vascular and neurological assessment, which includes an assessment of the lower limbs and feet, will help identify problems early. Future developments may incorporate self-educational programmes and the need for podiatrists to be part of the rheumatological multidisciplinary team. Overall, this study showed that opportunities for innovation and improvement in RA services exist and need to be pursued vigorously including the development of a business case for a combined DHB-academic post in podiatry.