Early RA
Advances in early RA
-
Functional loss occurs early and once present is often irreversible [5].
-
Mortality rates for RA are increased [10].
-
A biological 'window of opportunity' probably exists whereby intervention can alter the ultimate pathogenetic fate for the disease, leading to improved outcomes [11‐14]. This is supported by evidence which indicates that early introduction of most treatment modalities is associated with improved clinical response rates. Early intervention with potent biological agents appears to offer profound improvements in clinical response rates and in the magnitude of benefit. A modest proportion of patients may achieve subsequent drug free periods of remission. A new strategy in early RA called 'tight control' aims for remission and tailors the treatment strategy to individual patients' disease activity [15‐17]. Tight control is achieved by regular monitoring using composite, largely objective disease activity indices, the components of which capture both joint damage and functional impairment. Finally, good clinical practice indicates that it is difficult to justify delay in treating inflammatory disease once it is recognised.
Foot involvement in early RA
Non-pharmacological interventions for foot disease in early RA: evidence and guidelines
Scottish Intercollegiate Guidelines Network Management of early rheumatoid arthritis [69] | Clinical practice guidelines for the use of non-pharmacological treatments in early rheumatoid arthritis [37] | British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the management of rheumatoid arthritis (the first 2 years) [70] | European League Against Rheumatism recommendations for the management of early arthritis [71] | Multidisciplinary guidelines for the management of early rheumatoid arthritis [72] | |
---|---|---|---|---|---|
Multidisciplinary team care
| Podiatry is part of the multidisciplinary team | Podiatry is part of the multidisciplinary team Full-time dedicated podiatrist specialising in rheumatology is essential | Podiatry is part of the multidisciplinary team | ||
Access to foot health care
| 'Good practice' to offer all patients with early RA a podiatry referral | Access to podiatry should be available according to patient need Podiatry services should provide specific and dedicated service for diagnosis, assessment and management of foot problems associated with RA Timely intervention for acute problems is important | Foot care can relieve pain, maintain function and improve quality of life | ||
Foot Health Assessment/Review
| Metatarsal pain and/or foot alignment abnormalities should be looked for regularly | Annual foot review/assessment is recommended for patients at risk of developing serious complications in order to detect problems early Appropriate lower limb assessment for vascular and neurological status is needed Assessment of lower limb mechanics and foot pressures should occur | Annual foot review is recommended for patients at risk of developing complications | ||
Orthoses/Insoles/Splints
| Some evidence for the efficacy of foot orthoses for comfort, and stride speed and length | Appropriate insoles should be prescribed if needed | Orthoses are an important and effective intervention in RA | Use of orthoses has shown short term relief of pain only, rather than an effect on disease activity. | Joint protection included-orthoses not specifically mentioned |
Therapeutic footwear
| Appropriate footwear for comfort, mobility, and stability is well recognised in clinical practice but little available evidence | There should be a provision of specialist footwear if needed |
American College of Rheumatology Subcommittee on rheumatoid arthritis guidelines for the management of rheumatoid arthritis [73] | Arthritis and Musculoskeletal Alliance Standards of care for people with inflammatory arthritis [74] | Podiatry Rheumatic Care Association Standards of care for people with musculoskeletal foot health problems [75] | National Institute for Health and Clinical Excellence Rheumatoid arthritis National clinical guideline for management and treatment in adults [76] | British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the management of rheumatoid arthritis (after the first 2 years) [77] | Clinical Practice Guidelines for non-drug treatment (excluding surgery) in rheumatoid arthritis [40] | |
---|---|---|---|---|---|---|
Multidisciplinary team care
| People with inflammatory arthritis should have ongoing access to local multidisciplinary team Podiatrists are part of the multidisciplinary team. | Early referral for surgical opinion if required | ||||
Access to foot health care
| All people with a sudden 'flare-up in their condition should have direct access to specialist advice and the option for early review with the appropriate multidisciplinary team member | Timely access to foot health care - diagnosis, assessment and management Adequate information/education should be given for self-management and signs/symptoms of deterioration in foot health and need to access specialist help promptly | All patients with RA and foot problems should have access to a podiatrist | Every patient with RA should be informed of the rules of foot hygiene and of potential benefit of referral to a podiatrist A podiatrist should be consulted to treat nail anomalies and hyperkeratoses on the feet of patients with RA | ||
Foot health assessment/review
| Foot health care providers must understand the consequences of systemic disease on the feet and be able to identify warning signs that require timely referral to specialist medical care Musculoskeletal foot health assessment should include: General health; Foot health; Systemic factors; Lifestyle/Social factors; Pain management; Need for other assessments as required Foot health assessment should occur within 3 months of diagnosis - doesn't have to be done by foot health specialist Annual review of foot health needs are desirable - doesn't have to be done by foot health specialist Where there is substantial change (better/worse) in disease activity, foot health should be reviewed | All patients with RA and foot problems should have access to a podiatrist for assessment and periodic review of their foot health needs | Feet, footwear and orthoses should be regularly examined | |||
Orthoses/Insoles/Splints
| Non-pharmacological treatment recommendations include joint protection but do not specifically mention orthoses | Functional insoles and therapeutic footwear should be available to all people with RA if indicated | Limited evidence for the use of foot orthoses - no consensus regarding choice of orthoses but reduction of pain and improved function of the foot are reported | Customised orthotic insoles are recommended in the case of weight-bearing pain or static foot problems Customised toe splints may be preventive, corrective or palliative to enable the wearing of shoes Orthoses should be regularly examined | ||
Therapeutic footwear
| Semi-rigid orthotic supportive shoes can be effective for metatarsalgia - reduction in pain, disability, and improvement in activity as measured by the Foot Function Index have been reported | Patients should be advised about footwear Footwear should be regularly examined Extra-width off-the-shelf or therapeutic shoes thermoformed on the patient's foot are recommended when the feet are deformed and painful, or if it is difficult to put on shoes - such shoes reduce pain on walking and improve functional capacity Off-the-shelf therapeutic thermoformed shoes for prolonged use are indicated when other types of footwear have failed Palliative customized therapeutic shoes may be prescribed when the feet are seriously affected |
A new paradigm for podiatry in early RA
Early detection - widespread dissemination and uptake of referral guidelines
Targeted therapy - aggressive management of residual foot disease
Tight control of foot arthritis and disease monitoring
Outcome | Domain |
---|---|
CORE
| |
1. Swollen foot joint count | Active disease |
2. Tender foot joint count | Joint destruction/soft-tissue damage |
3. Foot Impact Scale-RA | Foot impairment and disability |
4. Structural Index | Foot deformity |
5. Radiographic erosions | Joint destruction |
EXTENDED
| |
6. Ultrasound core set | Active disease/joint destruction Soft-tissue disease |
7. Gait analysis - spatiotemporal, plantar pressure, joint motion and forces | Functional |