Introduction
(Article introduction authored by Conquest Editorial Team)
A clinical practice guideline (CPG) was developed to provide podiatric recommendations for managing rheumatoid arthritis (RA), focusing on conservative care. The guideline was created by a multidisciplinary team, including podiatrists, rheumatologists, and other healthcare professionals.
Key findings highlight the effectiveness of chiropody in relieving hyperkeratotic lesions and the benefits of custom foot orthoses in reducing pain and improving functionality. Therapeutic footwear is crucial for mobility, and surgical interventions are reserved for cases unresponsive to conservative treatments. The guideline underscores the importance of early detection and tailored care to improve patient outcomes.
Methods
Creation of the guide development group (GDG)
A multidisciplinary team was selected with the intent to get all relevant groups experienced with RA. The group was made up of experts in GPC methodology, health professionals and patients from different geographical areas (Malaga, Alicante, Tenerife, Granada and Sevilla, increasing the CPG value, dissemination and implementation. This is reflected by: five podiatrists, two rheumatologists, three nurses, one orthopaedic surgeon, one physiotherapist, one occupational therapist and four patients with RA. The multidisciplinary team was selected for its extensive experience in the management of RA and for its research career focused on RA.
The composition of the GDG is described below:
Coordination: a specialist in foot rheumatology, as principal investigator (PI) and a specialist in CPG methodology coordinated the clinical and methodological aspects of the CPG.
Group of experts: chosen for their qualities, experience and knowledge of RA. They were responsible for the development of the CPG recommendations.
Peer reviewers: Methodological experts were tasked with systematically reviewing the available scientific evidence and developing the information that serves as a basis for the expert group to make recommendations.
Patients: Two patients participated in the processing group and two patients participated as external reviews. All of them were patients from the Regional University Hospital of Malaga, Spain.
To ensure the optimal progress of the project, a detailed schedule was devised. None of the members of the group had conflicts of interest.
Formulation of clinical questions
Initially, the scope and objectives of the guideline were collaboratively defined and unanimously agreed upon by all members of the GDC, including experts, patients, and through reference to scientific literature. The formulation of clinical questions followed a consensual approach, ensuring a structured format aligned with the Patient, Intervention, Comparison, and Outcome (PICO) framework.
This not only enhances the scientific rigor but also facilitates the formulation of recommendations. Patient involvement remained integral throughout the entirety of the process. Subsequently, upon reaching consensus on the proposed objectives, clinical questions were established to address these objectives. Preferably, we sought to answer these questions through systematic reviews and meta-analyses.
Finally, the PICO questions that were answered were:
- What is the role of the implementation of foot care in improving health, the ability to move autonomously, independence and functionality, and improving quality of life in patients with RA compared to not implementing foot care?
- What is the most commonly used foot care in RA patients with foot and ankle involvement?
- What indicators suggest progression of foot and ankle involvement in RA disease?
- How to improve foot and ankle symptoms in RA?
- How to implement foot care in patients with RA?
Literature search, evaluation and synthesis of evidence
A systematic review of the scientific literature was carried out and in cases where there was no scientific literature, a Delphi survey was carried out.
Inclusion and exclusion criteria
Studies were included if they presented the following characteristics.
- Population: Adult patients (over 18) diagnosed with RA and/or diagnosed according to the 2010 RA criteria approved by the American College of Rheumatology and European League Against Rheumatism.
- Intervention: conservative and non-conservative foot care.
Outcome variables:
- Primary Outcome – Improvement in Foot Health: Reduction in foot pain as measured by the Foot Function Index (FFI) or Visual Analog Scale (VAS) scores.
- Secondary Outcomes: Improved Health: Lower overall RA disease activity scores, such as the Disease Activity Score 28 (DAS28), indicating better systemic health.
- Autonomous Movement: Increased ability to perform daily activities without assistance, measured by the Health Assessment Questionnaire Disability Index (HAQ-DI).
- Independence: Enhanced self-sufficiency in personal care and mobility tasks, potentially assessed through patient-reported outcome measures.
- Functionality: Improved physical function, specifically in the lower extremities, measured by the Lower Extremity Functional Scale (LEFS).
- Quality of Life: Higher scores on the Rheumatoid Arthritis Quality of Life (RAQoL) questionnaire or the Short Form Health Survey (SF-36).
- Symptoms: Reduction in specific RA symptoms such as joint swelling, stiffness duration in the morning, and the number of tender/swollen joints.
- Adherence to Treatments: Higher rates of compliance with prescribed medication and non-pharmacological interventions, monitored through patient self-reports or pharmacy refill rates.
- Reduced Variability: Decreased diversity in treatment approaches among healthcare providers, indicating standardization of care practices, assessable through review of medical records or surveys.
- Study design: systematic reviews or meta-analyses and randomized clinical trials, observational studies and case-control studies.
Assessment of the quality of the studies
Two GDG members assessed the risk of bias in individual studies. The Cochrane Handbook was used for RCTs, and the Newcastle-Ottawa Scale (NOS) for observational studies, evaluating selection, performance, detection, and reporting bias. Each RCT was assessed for biases in randomization, intervention deviations, outcome data, outcome measurement, and outcome reporting. PRISMA guidelines were followed for systematic reviews and meta-analyses.
Formulation of recommendations
Recommendations were formulated by carefully considering the quality, quantity, and consistency of scientific evidence, along with their clinical relevance. Contentious recommendations were resolved through GDG consensus. To support informed decision-making, educational materials tailored to patients and their families have been included in Annex 9, aiming to improve communication and foster collaboration in healthcare.
GPC external review
An external review of the guideline was conducted by experts in RA and guideline methodology to enhance its validity and accuracy. OpenReuma, a non-profit rheumatology association, helped with public exposure and dissemination by making the guide available on their website and collecting feedback through a form.
Evaluation and synthesis of the evidence
The GRADE methodology was used to evaluate the quality of evidence. Recommendations were scored by the GDG on a 0 to 10 scale, with those averaging ≥6 advancing in the CPG process. Recommendations scoring below 6 were thoroughly discussed to decide on their inclusion or exclusion.
Results
Recommendations were divided into treatments: chiropody, footwear, foot orthoses, surgery, self-care, ulcer management, physical therapy, and injections. Except for physical therapy, all recommendations were based on a systematic literature review and GRADE analysis. Where literature was lacking, a Delphi survey gathered expert consensus. The findings show varied evidence levels for different treatments in RA foot and ankle management, detailing the quality of evidence and recommendation strength.
- Chiropody: The GRADE analysis indicates a very low level of evidence regarding the efficacy and outcomes of chiropody interventions (Annex 1).
- Footwear: The assessment of therapeutic footwear, including both custom and standard options, yielded a moderate to very low grade of evidence (Annex 2).
- Foot Orthoses: The evidence supporting the use of foot orthoses was rated as moderate (Annex 3).
- Surgery: Surgical interventions for foot and ankle issues in rheumatoid arthritis patients were found to have a very low grade of evidence (Annex 4).
- Self-Care: The effectiveness of self-care strategies, including education on foot health and routine care practices, was assessed to have a very low level of evidence (Annex 5).
- Ulcer Management: Similarly, the GRADE assessment for ulcer management strategies yielded a very low level of evidence (Annex 6).
- Injections for Joint and Tendon: The evaluation of the efficacy of injections, specifically in joints and tendons in the foot and ankle, also received a very low evidence grade (Annex 7).
The recommendations are as follows:
Chiropody Recommendations:
Chiropody is recommended for patients with RA to remove painful hyperkeratotic lesions, which can reduce pain and improve functionality. However, chiropody alone is not sufficient; it should be combined with appropriate footwear and foot orthoses to effectively manage foot problems in RA patients. This combination helps prevent deeper tissue damage and enhances overall treatment outcomes.
Footwear recommendations
What are the benefits of therapeutic footwear for patients with RA?
Therapeutic footwear, whether custom-made or off-the-shelf, is crucial for RA patients, as it helps reduce pain and improve mobility by accommodating foot deformities and reducing pressure points.
While therapeutic footwear is beneficial, many RA patients, especially women, find it unattractive, expensive, or hard to find, leading to dissatisfaction and negative social and emotional impacts. Although standard footwear may be more aesthetically pleasing, it often worsens foot issues and is less effective in pain reduction and physical function improvement compared to therapeutic footwear.
Foot orthoses recommendations
What are the effects of foot orthoses for patients with RA?
Foot Orthoses for RA Patients:
Foot orthoses are a key conservative treatment for RA-related foot problems, aimed at reducing pain, disability, and improving quality of life. Both personalized and standardized orthoses have proven effective, particularly when used early in the disease.
Early intervention can reduce pain within the first 3 months and improve long-term foot health, potentially delaying or avoiding orthopedic surgery. Orthoses vary in materials and design, with soft materials reducing forefoot pressure and rigid materials helping with rearfoot pain. However, more high-quality studies are needed to refine their use.
Surgical recommendations
Which foot surgeries are recommended for patients with RA?
Osteoarticular surgery for RA patients aims to reduce deformity, pain, and preserve functionality, especially when conservative treatments fail. While surgery can alleviate pain short-term, it isn’t curative, and long-term studies show increased pain and deformity recurrence.
Common procedures include arthroplasty, arthrodesis, and osteotomy, particularly for MTP joints. Although surgeries like first MTP arthrodesis and total ankle replacement are common and generally safe, complications like ankylosis and increased stiffness can occur, especially with long-term outcomes.
Self-care recommendations
Is self-care recommended for patients with RA?
Self-care is vital for managing RA, aiming to alleviate symptoms, promote health, and maintain patient independence. It involves health education, social support, and physical function. RA patients may struggle with self-care due to disease-related disability, making early foot care crucial. Effective self-care includes daily hygiene, skin and nail care, appropriate footwear, toe spacers, foot orthoses, and specific exercises. These practices help maintain mobility, independence, and overall health.
Ulcer management recommendations
Is it recommended the care of skin ulcers in patients with RA?
Foot problems in RA patients may require interventions for skin lesions and ulcers. Ulceration is more common in females with long-term RA, often occurring at various sites. As the disease progresses, foot deformities and trauma from footwear increase ulcer risk, with prevalence between 10-13%.
Ulcers are typically found on the toes and rearfoot, particularly on the dorsal aspect of hammertoes and the plantar metatarsal heads. Older age and disease duration heighten ulcer risk, and targeted therapies can further increase susceptibility to infections and hinder tissue repair.
Physical therapy recommendations
Which type of physical exercise is recommended for patients with RA?
Non-pharmacological treatments, used alongside medication, include various physical therapy modalities. Physical exercise is crucial for reducing pain and improving function, with moderate, supervised exercise recommended for those with limitations. Effective exercises enhance flexibility, muscle strength, and cardiovascular fitness.
Low-impact activities like Nordic walking, cycling, and water exercises are ideal, with moderate to high-intensity training showing positive effects. Specific exercises for foot and ankle OA, including stretching and strengthening, can also reduce pain.
Electrotherapy, thermotherapy, and low-level laser therapy offer additional pain relief and functional benefits. Personalized exercise programs and careful use of these modalities can significantly improve outcomes for RA patients.
Injection recommendations
Which are the effects of corticosteroid injection for patients with RA?
Intra-articular corticosteroid injections are commonly used for RA, especially effective in the knee joint. They provide short-term relief from pain, stiffness, and improve function, although this effect may sometimes resemble a placebo.
Triamcinolone hexacetonide is particularly effective, with longer-lasting benefits due to its microcrystalline properties. These injections are also useful for tenosynovitis when combined with foot orthoses.
Despite their benefits, repeated injections can lead to local deterioration. Hyaluronic acid injections also improve foot function and pain in the short term. Accurate needle placement, ideally guided by ultrasound, enhances the effectiveness and reduces the risk of extra-articular injections.
Discussion
This study provides the first comprehensive clinical practice guidelines (CPGs) focused on managing foot and ankle pathologies in RA patients, addressing a critical gap in the literature.
It emphasizes the importance of early and non-pharmacological treatment for preventing foot dysfunction, pain, and disability, which significantly impact the quality of life.
Currently, there are no specific evidence-based guidelines for non-pharmacological foot treatments in RA, leading to variability in clinical practice. This guide aims to reduce practice variability, improve patient outcomes, and enhance the management of foot and ankle problems in RA.
It incorporates patient perspectives and identifies areas for future research, such as the impact of physical exercise, foot surgery, and patient self-care. The guidelines will help healthcare professionals and provide valuable information for RA patients to improve their care and quality of life.
Conclusion
Our study culminates in evidence-based recommendations for foot and ankle management in rheumatoid arthritis patients, highlighting the utility of chiropody, foot orthoses, and therapeutic footwear in reducing pain and enhancing mobility.
Custom solutions are particularly emphasized for their role in improving quality of life. Surgical options are advised for cases refractory to conservative measures, aiming to preserve functionality. The importance of self-care and education in promoting independence is also underscored. These guidelines serve as a foundation for clinicians, emphasizing the need for ongoing research to refine and update therapeutic strategies.
References
1. Chan PJ, Kong KO (2013) Natural history and imaging of subtalar and midfoot joint disease in rheumatoid arthritis. Int J Rheum Dis 16:14–18
2. Stolt M, Suhonen R, Leino-Kilpi H (2017) Foot health in patients with rheumatoid arthritis—a scoping review. Rheumatol Int 37:1413–1422
3. Turner DE, Woodburn J (2008) Characterising the clinical and biomechanical features of severely deformed feet in rheumatoid arthritis. Gait Posture 28:574–580
4. Riente L, Delle Sedie A, Iagnocco A et al (2006) Ultrasound imaging for the rheumatologist V. Ultrasonography of the ankle and foot. Clin Exp Rheumatol 24:493–498
5. Göksel Karatepe A, Günaydin R, Adibelli ZH et al (2010) Foot deformities in patients with rheumatoid arthritis: the relationship with foot functions. Int J Rheum Dis 13:158–163
6. Louwerens JWK, Schrier JCM (2013) Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options. Int Orthop 37:1719–1729
7. Van Der Leeden M, Steultjens MPM, Terwee CB et al (2008) A systematic review of instruments measuring foot function, foot pain, and foot-related disability in patients with rheumatoid arthritis. Arthritis Care Res off J Am Coll Rheumatol 59:1257–1269
8. Turner DE, Helliwell PS, Emery P, Woodburn J (2006) The impact of rheumatoid arthritis on foot function in the early stages of disease: a clinical case series. BMC 9. Musculoskelet Disord 7:102. https://doi.org/10.1186/1471-2474-7-102
9. Álvaro-Gracia JM (2019) Guía De práctica clínica Para El manejo de pacientes con artritis reumatoide (GUIPCAR). Soc Española Reumatol Madrid Ed Doyma
10. Allen A, Carville S, McKenna F (2018) Diagnosis and management of rheumatoid arthritis in adults: summary of updated NICE guidance. BMJ 362
11. Maese J, De Yébenes MJG, Carmona L et al (2012) Estudio Sobre El manejo de la artritis reumatoide en Espana (emAR II). Características clínicas De Los pacientes. Reumatol Clínica 8:236–242
