Accepted Article

Nicola Dalbeth Nicola [email protected] This by is protectedarticle reserved. Allrights copyright. doi: 10.1002/acr.23832 lead to differences between this version and the throughbeen the copyediting, pagination typesetting, which process, may and proofreading hasThis article been accepted publicationfor andundergone peerfull but review not has c b a Sarah Stewart controls sex-matched and age- with comparison a erythematosus: lupus systemic with people in ankle characteristics and foot Objectively-assessed Article :Original type Article Ash Aiyer Ash Auckland 1142, New Zealand. Keith Rome Keith Competing Interests: Interests: Competing New Zealand. Technology, Private92006, Bag Auckland 1142, ZealandNew Zealand. DepartmentRheumatology, of Auckland DistrictHealth Board, P.O. Box 92189, Auckland, DepartmentInstitute, Research Health & Rehabilitation ofPodiatry, Auckland of University Faculty ofMedicalHealth and Sciences, The University Auckland,of Private Bag 92019, a , BHSc , BHSc a , BSc, FPodM, MSc, PhD FPodM,, BSc, a b,c , BHSc, PhD, corresponding7690; 21 176 , BHSc, PhD, author: 0064 , MBChB, MD, FRACP MD, FRACP , MBChB, The authors declare no competing interests. competing no declare authors The Version of Record. Please Version as this cite of Record. article

Accepted Article management. ofSLE part as health assessments importance foot of muscle strength andaltered whenpatterns gait compared to Thiscontrols. highlights the f of evidence shown objective Conclusion. greater foot pain ( footpain greater compared to controls (all (all controls to compared velocity and step, highercadence and swing, doublestancesingle and and support times abnormal ABI ( ( This by is protectedarticle reserved. Allrights copyright. regions (all allfoot for timeintegrals higher pressure plantarflexion, dorsiflexion, inversion eversion and (all Results. pain. foot index and models. pressurePlantar andgaitmodels were walking adjusted for velocity, body mass includingpainvisual a100mm foot sc analogue characteristics. Self-reported measure footpain and of were impairment assessed also (ABI), index brachial ankle perception (VPT), muscle strength, joint motion, foot posture, footproblems, protectivesensation, vibratory included characteristics foot Objectively-assessed ankle. and foot the assess comprehensively Methods. tocontrols. age- sex-matched and Objective. ABSTRACT Funding: P =0.007), higher foot problem scores ( Compared to controls, participants with SLE had lower muscle force muscle Compared SLE lower for force controls,with participants had to This study was byArthritisfunded New Zealand. 54 SLEcontrol and 56 participants studyattended a visit designed to To objectively identify and foot ankle characteristics inpeople SLE with compared People with experience SLE a wide-ran OR =3.13, P <0.001).

P P =0.044).Participantshad peak lower also pressure SLE and with <0.001). Compared to controls, participants with SLE also reported oot and ankle diseaseoot and in people with SLE, reduced including P =0.001), higher VPT ( plantar pressure and spatiotemporal gait gait andspatiotemporal pressure plantar ale. Data were analysedale. were Data using regression ge of foot complaints. This study has study has This foot ge of complaints. P <0.001), lower step and stride length, P <0.001), posture higher indices foot P =0.001) and more frequent Accepted Article This by is protectedarticle reserved. Allrights copyright. function, including strength characteristicsmuscle have previously notand gait been difficulty completeor a inability towalk [7]. However, objectively-assessedmeasures offoot impairmentlimitation [6-8]. andactivity More than one-third withSLEeitherof people report foot deformity. People withSLE report foot- loweralso and limb-related functional include joint andswelling, impairedpain circulation,nail compromised and skin and health, complaintsreported bypeople with SLE beenhave highlightedsurvey in studies [6, 7],and have been reported in the feet compared to the andwristsdegreehands [5].The of foot SLE [4].Agreater prevalencesonographica of with people in ofinvolvement area under-appreciated an as identified been have The feet [2,limitation reduced capacity 3]. and functional activity fatigue, chronic associated with of life quality health-related decreased a SLE report the cardiovascular musculoskeletal, cutaneous, multi-organ involvement[1]. The clinical presentation ofSLE is diverse, with manifestations in Systemic lupus erythematosus rheumatic anautoimmune (SLE) is characteriseddisease by • • • AND INNOVATION SIGNIFICANCE

after adjusting for foot pain. pain. foot for after adjusting People SLE with demonstrated altered patterns, gait including velocityreduced gait even reduced strength, when controls. muscle compared to People SLE with exhibit structuralfunctional and evidence of foot disease including SLE. in with people This was the studyfirst comprehensively to a lly-evident inflammatoryabnormalities joint and neurologicaland systems [1]. with People ssess objective foot and ankle characteristics characteristics ankle and foot objective ssess Accepted Article This by is protectedarticle reserved. Allrights copyright. otherarthritic conditions. inflammatory All pa minors), required aninterpreter, recent surgery neuromuscular foot had trauma, or or had or Participants both excluded in were if were groups youngerthey than 20years age (legal of Auckland Universityof Technology staff(AUT) through poster and newsletter advertising. involvement. Age- 5 years)(within sex-matched and participants control were recruited from systemicwithout lupus cutaneous had they were if excluded [9]. SLEParticipants with SLICCBoards inAucklandthe 2012 aphysicianSLEhad diagnosis criteria and to according of rheumatology clinics from Auckland, Counties Manukau andWaitemata District Health Auckland, Participants New Zealand. withrecruited SLE were secondary-care from A cross-sectional observational study was undertaken. All participants were recruited from Participants METHODS matched control participants. aimedand identify ankle foot to characteristics quantify extent problems the nature offoot and foot objective assesses which research, Further problems. foot manage and prevent to strategies assessments central are inidentifying needs of the informing the patient and treatment and quickly practiceclinical in to determine Such the health patients. status foot of evaluated inpeopleSLE. with Objective podi

atric assessments can be undertaken efficiently rticipants provided written informed consent written informed rticipants provided and ankle characteristics, is warranted to warranted is characteristics, ankle and in people with SLE compared to age- andsex- toage- compared with people SLE in experiencedstudy This SLE. with bypeople Accepted Article This by is protectedarticle reserved. Allrights copyright. th on or plantarflexion, foot for the aspect of thedynamometer to proximal was positioned dynamometerstationary while theparticipantex examiner the ‘make’inwhich the held technique the group using each musclefor recorded were seconds five to of three contractions consecutive Three position. aneutral in foot and leg lower the stabilised examiner The extended. knees and flexed hips with testing dynamometer (CIT Technics, Haren, Netherlands) Participants[12]. were seated during plantarflexion, dorsiflexion, inversion eversion was using measured CITEC and hand-held a allocation, objectiveundertook all Isometric ankle muscleassessments. force for Asingle experienced podiatric researcher, who notwas blinded to participant’s the group characteristics foot musculoskeletal of Assessment sedimentation rate (ESR), andC-reactive protein (CRP)). laboratory results within 4months the before study visit (creatinine, erythrocyte disease activity (SLEDAI-2K [11]), medication, comorbidities recent ifavailable, and, Disease characteristics were recorded forparticipants SLE, with including disease duration, obtained the 68/66 and tender/swollen all[10] was completed count participants. joint on visit clinical single a attended Participants assessment clinical and Demographic 16/209). prior to collection. Ethical AUT data approval was Ethics obtained Committeefrom (AUTEC at AUT,New Zealand.at Demographic data were e dorsum of the foot dorsiflexion; on for foot e ofthe the dorsum metatarsophalangeal jo erted maximal external force against it. The The it. against external force erted maximal ints on the plantar Accepted Article This by is protectedarticle reserved. Allrights copyright. are criteria six for the scores The to +2). (-2 scale five-point a on scored was criterion the six-criterion-based examiner assessed observations ofthe rearfoot forefoot. Each FPI and while position weight-bearing relaxed a in stand to instructed were participants assessment moderate intra-raterreliability for theassessment of posturefoot inadults [17].During Foot type was assessed using theFootPosture Index (FPI) demonstrated[16], which has analysis. for used were foot each for measurements three The examiner measuredthe angle between anteriorthe tibia and the wall. The averages of the floor. with contact in remained heel their ensuring while wall, the on drawn line vertical a touched knee their so forward lunge to instructed were They the line. over positioned over a line perpendicular drawn wall, to a theirthe centrewith of second heel and toe using the weight-bearing lunge test [15].Participants were positioned with their tested foot the participant totheir endrange for eversion inversion.and Ankle dorsiflexion was assessed positioned atthe anterior Withankle. the relaxedinankle position, a the examiner guided the longitudinal midlineof the second metatarsal with the centre thegoniometerof extended [14].The examiner located andmarked midlinethe of the anterior and lower leg motion. Ankle inversion eversionand with were assessed participantsseated and knees of the jointand apassive dorsiflexion force was the applied to hallux until range endits of centre with the aligned was goniometer The marked. phalanx were proximal metatarsal and Participantsthe were with seated of extended knees positioned first theshafts and Range motion for 1MTPJof dorsiflexion assessedwas using ahand-held goniometer [13]. analysis. in the used foot each were for measurements three the of maximum The eversion. for shaft metatarsal inversion; medial shaft for metatarsal of the and the the lateral on aspect first aspect of fifth Accepted Article This by is protectedarticle reserved. Allrights copyright. gait the of calculation to Prior [20]. speed walking comfortable a at walk to instructed were Participants US). New Jersey, Inc., Systems, (CIR system walkway GAITRite electronic Spatial andtemporal parameters during barefoot repeatedeach foot. trials for three from computed were Means region. each for computed were (kPa*s) integrals five, hallux andthe toes the lesser [19]and plantar pressurepeak pressure (kPa) and time plantar into: theheel, foot midfoot, meta first the mask to used was 6.61 Foot® Version Research The steps. more two least at platform for stepstepparticipantto continue and second on past their on to platform the walking the ga two-step a and USA) MA, (Boston, system Dynamic plantar pressure capturedwas during Assessment plantar pressureof spatiotemporaland parametersgait each participant.score a for total to give summated were foot each for Points [18]. point one scored each were exostoses and lesions, sandincluding calluses corn andother prominences, bony including tailors bunions severe points); (3 lesser deformities, toe hammer including toes, andclaw hyperkeratotic or (1point), (2points) points); mild 5moderate or as hallux points)graded no (0 was valgus coversskin foot pain,footdeformity and lesion which [18] using Problem Score the Foot determined were problems offoot The presence (highly pronated). score from summated (highly ranging overall each supinated)-12 for foot to an to give +12 it initiation protocol which required the it initiation protocol which the required tarsal, second metatarsal, metatarsals three to three metatarsals metatarsal, second tarsal, s. Foot pain was dichotomised as yes (scored (scored yes dichotomisedas pain was s. Foot barefoot barefoot walking using TekScan the MatScan® walking were collected using xa 4.88 0.61m Accepted Article This by is protectedarticle reserved. Allrights copyright. defined detect an inability as to the monofilament at > site metatarsal was Each [21]. assessed head) testing athree-site protoc monofilament using Semmes-Weinstein a 10g using assessed was foot plantar ofthe sensation Protective characteristics foot neurovascular of Assessment the three repeated trials each for walking parameter. andand swing, double step, supportsingle stance, and Means weretimes. computed from compute the parameters:following velocity,step cadence, andstride supportlength, base, correctly identified..The GAITRite software (GAITRite® gold,Version 3.2b) was used to parameters, the data reviewed were on the screenmonitor ensurehad been footfalls that to dorsalis pedis, posterior tibial and arteries brachial were determined bilaterally using an Ankle Brachial was determin usedIndex (ABI) to analysis. the for used were foot each for taken were repetitions three of average temperature from the plantar fifthmetatarsal thirdwere recorded.first, heads and The average The (DermaTemp). thermometer infrared an using assessed was temperature Skin [22]. of >25mV athreshold as defined was perception vibratory of Aloss analysis. for the used foot were each for measurements of three average The stimuli. vibratory the felt they when amplitude waseven at increased ratean from the 0mV and wasparticipant asked to indicate do the on placed biothesiometer a using assessed Participants rested for > for rested Participants 5minutessupine in a position before once and loss of sensation for each foot was each footwas sensation for of loss and once ol (hallux, third metatarsalol (hallux, third fifth head, e thee presence peripheralof arterial disease. rsal The fold. hallux, nail proximal tothe 1 sites1 [21]. Vibration perception was testing. Systolic pressure of the Accepted Article This by is protectedarticle reserved. Allrights copyright. activities which for participants torate asked are difficulty the withthey have had in each the activities daily living of andthe other to recreational activities. includes section Each 10 wasmeasure used to lower limb function. LLTQThe consists oftwo sections, one related to Th participant. each for calculated was of 38 ‘on some days’ 1)or (scored score the‘on most/everyday(s)’ month. 2)in past A total (scored item each to relating Statements appearance. [25] which is a 19-item index measuring foot-related functional limitation, pain, physicaland Disabling assessed pain foot was Manchester using the and Disability Pain Index Foot (MFPDI) stratified into: rearfoot. toes,forefoot, midfoot and further were regions 10 The 0). (scored or ‘absent’ 1) (scored ‘present’ as region for each midfoot, medial arch, plantarankle, heel, posterior heel). The presence of recordedpain was diagrams dividedwere 10 into regions (1MTP, hallux, lesser great toe, plantar forefoot, toes, The [24]. diagrams validated on pain of areas in shading by foot each on experienced specific foot pain was assessedalso in which participants indicated theareas ofpain le atthe pain’ ‘no with anchored (VAS) scales Right and pain over the foot left weekpast were assessed using 100mm visual analogue disability and pain patient-reported Assessment of [23]. of value ABI analysis. An divided by the highest ankle pressure for each side.The lower of the two values was used for 8MHz Doppler andsphygmomanometer.probe The higherof the twobrachial arteries was ≤ 1.00 was consideredocclusive abnormal andindicative of disease e LowerLimb Task Questionnaire (LLTQ) [26] ft and ‘extreme pain’ at ‘extreme the right. Region- pain’ ft and at were answered‘none time’ the of (scored 0), Accepted Article This by is protectedarticle reserved. Allrights copyright. correlation [28]. the Due potential objective footpain to influence of on measures of between-foot-side a for thatwould allow eachfoot-side for averaged analysismeasures of random effect for foot-side were included [28].This analysis producesresults identicalan to participant-nested and effect randomparticipant-specific a which modelling in approach the models repeated right feetaccounted measures left throughfor taken from and mixed- a determine difference the in outcomemeasures between the two Where groups. appropriate, regression and (ordinallogistic data), regressionbinary were(dichotomous data) to used and Shapiro-Wilk).Linear regression (continuous outcome measures), multinomial logistic (Kolmogorov-Smirnov tests formal and scatterplots) and plots, Q-Q (histograms, inspections (SD) for continuous Continuous outcomes were data. reviewed using for visualnormality All raw were described data separately for each within the project 54 participants with SLE controlsand 56 were ultimately recruited. controls. The power was set to 0.90 leveland of pain as 35.3 (22.9) mm for participants with autoimmune disease 20.5 and (24.9) mm in rheumatic disease [27]. arthritis) (rheumatoid literature pain measuring foot using 100mmVAS people in otherwith autoimmune SLE sex-matched and56 and controls. age- size samplebased This calculated on was previous this study computed 56 size for with with was participants participants Aof 112 sample total Statistical analysis no difficulty=4). =1, difficulty severe =0, (unable hours 24 past moderate difficulty =2,mild =3,difficulty and This assumes the mean (SD) values for foot foot for values (SD) mean the assumes This group as n (%) for categorical data and mean dataandmean forcategorical n(%) as group significance 0.05. time Due to constraints Accepted Article and disease(12) years. of15 duration are presented in ( This by is protectedarticle reserved. Allrights copyright. ( smoking of history a have controls, participants significantlySLEwith a had higherBMI ( participants were females middle-aged of European ethnicity ( thestudy. sex-matched Fifty-six age- and completedcontrols also majoritythe study. The of study. Eleven did not fulfilthe inclusion criteria, leaving 54 participants withSLE completing Invitation letters were posted to 448 patients with SLE. Ofthese, 65registered interest in the Participants RESULTS significance levels were reported. Data were analysed using IBM SPSS Statistics v24. their distributionsmultiplicity observedtest-statistics,alland null used, their but was adjustment for No alternatives. two-sided against ofsignificance level a 5% out at carried increases and BMI in velocity).gait hypothesis All tests testing)(excluding covariate were adjusted for the (due BMI linear to relationship between increasedpressure plantar and velo gait BMI and for adjusted was pressure pressure characteristics and gait were for adjusted footVAS. pain Inaddition, plantar structure andfunction,the regression models formuscle motion, joint force, FPI, plantar P <0.001) and swollen (

Table 2 Table P . Participants with SLE had a mean (SD) SLEDAI-2K score of 13.3 (9.7) (9.7) 13.3 of score SLEDAI-2K (SD) amean had with SLE . Participants =0.025) joint counts. Disease characteristics forparticipants with SLE P =0.046) or be unemployed ( city, and spatiotemporal parametersand were city, P =0.006) andhigher had tender P Table 1 Table =0.004), were more likely to ). Compared to ). Compared Accepted Article significantly lower velocity and cadence compared tocontrols (all and double support times compared to controls (all SLEsignificantlystep had stride lower and step, length and higher swing,stance andsingle all seven regions of the plantar foot (all plantarfoot the seven allof regions SLEsignificantly had lower peak pressure and significantly higher pressure-time integrals at parameters. and spatiotemporal Table 4 parameters gait spatiotemporal pressure Plantar and groups for halluxmotion,joint other valgus, deformitiesor (all This by is protectedarticle reserved. Allrights copyright. ( with higher SLE significantly FPI hada a posture also indicativefoot of more pronated plantarflexion, dorsiflexion, inversion eversion and of the ankle (all for force lower muscle significantly had SLE with participants controls, Compared to Differences musculoskeletal footcharac in characteristics foot Musculoskeletal P =0.007) and a greater problemfoot score ( presents the between-group differences for plantar pressure, pressure time integrals integrals time pressure pressure, plantar for differences between-group the presents After adjusting for BMI and gait velocity, participants velocity, gait BMI and with adjusting After for P <0.001). After adjusting for BMI, participants with teristics between groups are presented in P =0.001). There were nodifferences between P <0.001). Participantswith SLE also had a P >0.05). P P <0.001). <0.001). Participants Table 3 . Accepted Article pain in > in pain had SLE with participants of (43%) feet Forty-six 44%). feet, (n=47 SLE with people in pain foot for region overall common most the was rearfoot The 32%). feet, (n=34 ankle and 37%) sites were in pain thelesser (n=41 SLE foot toes for feet, 38%), midfoot (n=40feet, dorsal pain compared to controls (62% vs. 29%, MFPDI ( MFPDI controls, participants with SLE reported significantly worse foot pain VAS scores ( scores VAS pain foot worse significantly reported SLE with participants controls, Table 6 disability and pain Patient-reported were observed between groups for the remaining neurovascular measures (all (all measures neurovascular remaining for the groups between observed were impaired foot and ankle muscleimpaired which changes, notbeen footankle have gait and assessed function and functional andneurovascular problems observed foot inthe current study, including The multi-system heterogenic reflectednature ofSLE is in diversitystructural, the of DISCUSSION This by is protectedarticle reserved. Allrights copyright. ( Participants significantly with reduced indicative SLE had VPTs higher of vibratory perception Table 5 characteristics foot Neurovascular P =0.001) and were more likely haveto abnormal ABI ( presents the differences in patient-reported outcomes between groups. Compared to to Compared groups. between outcomes patient-reported in differences the presents presents the differences between groups for the neurovascular characteristics. characteristics. neurovascular the for groups between differences the presents P 2 regions. <0.001),LLTQ and (

P <0.001). Participants SLE with were more likely to have foot OR =4.31, P <0.001). The most common individual OR =3.13, P =0.044). No differences=0.044). No P >0.05). P <0.001), Accepted Article This by is protectedarticle reserved. Allrights copyright. to factors beyond these alterationsIt factors. possible structure is infoot that andposture, analysis velocity adjusted for gait and pain, that meaning may findingsfoot the beattributed 35],the current painpresence [34, of speed foot or theslow walking a considered result of a most commonly is Althoughrheumatoid thisincluding [33]. arthritis diabetes and [32] populations, other in pain and damage tissue withunderlying associated time are integrals control participants, thecumulative preffect of in under the foot area each at load though maximal withintegrals of inthe SLE. allareas plantar in These even suggest people results foot that Results the from current studyshowed reduced peak pressures and increased pressure time people with SLE [2]. reduction inphysical symptom fitness aconsequence experienced a fatigue; as of by80% of sh and stability for plane motion walking,requires which adequate sagittal motion plane forforward progression and frontal and ankle muscle strength is important performingin daily activities,functional including limb muscle people SLE,groups with in including and quadriceps hamstrings 29, 30].[3, Foot in the current study are similar previousto studies when assessing functionofmajor lower Thereductions plantarflexion, in dorsiflexion, eversion inversion observedand muscleforce problems, including wide-spread pain, disabilityfunctional andactivity limitations. previouslyin this population. People with SLE report also a range foot-and ankle-relatedof ock absorption [31]. Muscle weakness in SLE may be due to a to be due SLE in may weakness Muscle [31]. ock absorption essure over time is very high. High pressure pressure High high. very is time over essure people low, relativeSLEwith is to that of Accepted Article This by is protectedarticle reserved. Allrights copyright. in this population [46]. extremitiesaccounting for chilblains and theoccurrence high of andRaynaud’s phenomenon fairly prevalent inpeople with [41-43] SLE resulting in decreased blood flow to the of participants studyin the current ABIvalues. abnormal had Peripheral disease vascular is lower limbmotorsensory and nerves in people withSLE [39, 40]. Finally, almostone quarter nerve fibre function.Nerve conduction studies significant shown have also deterioration of thresholds in SLE with people comparison in tocontrols, indicating impaired large peripheral Consistent with previousresearch [39], the current study found greater vibration perception [37]. controls from different consistent with previous studya whichprevalence the found hallux of wasvalgus inSLE not lesions and hyperkeratosis observed also peoplewere between with controls. SLE This and is Similar bony rates deformities,of including hallux valgus as andclawed welldigits, skin as and bone lesions people in with 37] SLE [36, the non-erosiveand SLE nature arthritisof [38]. joint radiographicfoot sonographic and reflect the infrequency of maycurrent study. This Limitationsmotion joint were to foot not a incharacteristic feature the with people SLE in sensation, may contribute these to altered gait peoplepatterns in with SLE. as resulting musclefunction strengthand to foot changes from well as reduced deficits Accepted Article This by is protectedarticle reserved. Allrights copyright. which over-estimationmayto lead prevalenof the been mayproblems have Finally,foot with people participants, and therefore influencedmay have strength the ofbetween differences. group been introduced the podiatricas researcher notblinded towas thegroup allocation of the useeveryday of Furthermore,footwear. for outcomepotential ascertainment bias may have barefoot walking which may not reflect ty patterns increasedrisk the forselection addition, Inbias.gait characteristics were assessed during Zealand), same they may sourcenot have from the come may population which have participants participants and SLE were with thesamecity recruited from (Auckland, New Auckland, NZandmay notrepresent ruralSLE in communities or Although globally. control clinics in secondarycare recruitedstudy from current were the participantsSLE in with Findings study shouldfrom this some beconsidered lightof in limitations. Firstly, the people with SLE compared to controls [37]. the rearfoot been have reported to morehave frequent synovitis ultrasound on imaging in caus the exact Although 7]. [6, survey data postal commonpeople area with in for therearfoot; SLE pain was also with consistent previous Although foot pain was multiplewide-spread often affecting and locations, most the Consistent with this, 62% of participants thein current SLEwith study reported pain. foot current self-reported pain foot SLEpeoplein with ranging from 33% [6, to 7,37]. 66% disability experiencedpeople by with SLE. Pr The resultscurrent highlighted the extent andmagnitudeself-reported of painand foot evious research has reported a prevalence of prevalence a reported has research evious e ofthis pattern unclear, ofpain is joints of more interested in a study of foot disease, disease, offoot study a in interested more ce of foot problems in people with SLE. with people in problems ce offoot pically exhibited in daily activity with the activity withthe exhibitedpically indaily Accepted Article This by is protectedarticle reserved. Allrights copyright. the ofparticipants. recruitment in Board) their Ng (Waitematafor assistance District Health Board), DrS.Kumar Manukau Board), (Counties District Corkhill and M. Health K. Dr and Dr M.We Lobo, thank DrR.Suppiah like would to ACKNOWLEDGEMENTS related pain, to disabilityand activity limitation. compared to matched controls. People report with also wide-range offootcomplaintsa SLE al strength and muscle ankle reduced and foot Insummary, people SLE exhibitwith objectiveevidence ankle of foot and disease, including CONCLUSION foot-specific interventions, including general podiatric care and footwear. current study, these findings thewarrant further need for research assessesrole that the of inappropriate theirfor level of pain and disability Along[45]. the with results the from are which shoeswear withSLE shown people Furthermore, that work has previous tissues diseases areeffective inreducing foot pain, impairment and disability [44]. rheumatological rheumatoid conditions, such as andother arthritis, foot connective gout skin clinical care, orthoses foot padding, suffering and advice footwear patients for from services,and nailincludingpodiatric that shownstudies have Existing SLE. of with patients the These management of results highlightpart health as assessments importance of foot the teredgait patterns pressure when plantar and and Dr N. Tugnet (Auckland DistrictTugnet Dr (Auckland N. Health and

Accepted Article This by is protectedarticle reserved. Allrights copyright. [7] [6] [5] [4] [3] [2] [1] REFERENCES

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Sacks D, Bakal CW, Beatty PT, Becker GJ, Cardella JF, Raabe RD, et al. Position Position al. et RD, Raabe JF, Cardella GJ, Becker PT, Beatty CW, Bakal D, Sacks Young MJ, A neurothesiometer N, AJ.Boulton the Every comparison of and Feng Y, Schlosser FJ, Sumpio BE.The Se years:Bohannon 20-79 speed walking of adults aged andmaximum RW.Comfortable Zammit GV,Menz Munteanu HB, SE. Reliability the MatScan(R) TekScan of system for MenzLord tomobility HB, contribution SR.The footproblems impairmentof and falls AquinoMRC, Avelar BS, Silva OcarinoPL, JM, Resende RA. Reliability Posture of Foot RedmondAC, Ouvrier Crosbie J, RA. Development rating anovel and validation of mmes Weinstein monofilament examination Accepted Article This by is protectedarticle reserved. Allrights copyright. [32] [31] [30] [29] [28] [27] [26] [25] [24] musculoskeletal research. Gait Posture 2018; 59:182-7. right andleft for limbs: dependenceAccounting improvingand statisticalefficiency in Rheumatol 2016;35:887-91. foot pain, impairment disabilityand rheumatoid arthritis:in case-control Clin study. a important differences. Phys Arch Med Rehabil 88:993-1001.2007; questionnaire: assessment of validity, an reliability, responsiveness, andminimal 85:107-13. Development and validationa questionnaireof assess to disabling foot pain. Pain 2000; repeatability of the scoring painof foot drawings. J AnkleFoot Res 2013; 6:44-50. 1998; 37:303-7. foot pressure riskpatients to identifyat forneuropathic footulceration? Foot JAnkle Surg Lupus 2012;21:271-8. D status women in with systemic erythematosuslupus compared healthywith controls. 29:474-81. 2002; J Rheumatol erythematosus. lupus systemic in disability and physical

Armstrong DG, Peters EJG, Lave KA,Athanasiou Brockett CL,Chapman GJ.Biomechanics ofthe ankle. Orthop Trauma 2016;30:232-8. Stockton KA, Kandiah JD, DA, Paratz Bennell KL. Fatigue, strength muscle vitamin and McCurdie I,WhiteBentleyTench Aerobic P,D'Cruz V, Vleck C, D. fitness, fatigue, D, collectedStewart from of data Vandal AC.Analysis K, Pearson DalbethS, N, J, Rome Morpeth T,Brenton-Rule A, Carroll M, Frecklington M, K.Rome and Fear offalling McNair PJ, Prapavessis H,CollierBassett J, S,BryantLarmer A, P. The lower-limb tasks AJ, Th Silman AC, Garrow AP,Papageorgiou Chatterton Muller BD, intra-rater K, Rome S,ThomasMenz HB, MJ, Roddy E.Inter and omas E, Jayson MIV, Macfarlane GJ. GJ. Macfarlane MIV, E, Jayson omas ry LA. Is there a critical level of plantar of plantar level a critical Is there LA. ry Accepted Article This by is protectedarticle reserved. Allrights copyright. [41] [40] [39] [38] [37] [36] [35] [34] [33] underestimating involvementtheir and functional impact? Clin Exp 2016; Rheumatol Ovalles-Bonilla JG, L, al.The in systemic et Valor feet lupus erythematosus; are we systemic erythematosus.lupus J Rheumatol 1990; 17:777-84. severely rheumatoid deformedin feetarthritis. 28:574-80. PostureGait 2008; 44:18-22. walking speeds inpeople with gout:a two-armsectional cross study. Gait Posture 2015; pain and disability andspatiotemporal parameters during ofgait self-selected fast and of plantar pressure and characteristics. gait Rheumatology (Oxford) 2006; 45:465-9. rolerheumatoid patients the in complaints: arthritis with damage, foot disability and pain lupus erythematosus: prospective a controlled study. Int Rheum DisJ 2013; 16:319-24. cutaneous vasculitis insystemic lupuserythematosus.Brain 2006;129:977-85. 1993; 88:41-6. study peripheral of neuropathyerythematosus. insystemic lupus Acta Neurol Scand erythematosus. Eur JIntMed 2008; 19:482-7. 34:609-17.

Hassan Habib Peripheral AA, HM, Eissa AA. arterial disease insystemic with patients Tseng MT, Hsieh SC, Shun CT, Lee KL,WM, al. Skin CL, Lin et Pan denervation and controlled A T. Torbergsen OA, Heriksen R, Salvesen G, Husby SI, Mellgren R, Omdal Pipili C,Cholongitas Sfritzeri A, E. Deforming insystemicarthropathy lupus Morales-LozanoMartinez-Barrio R, J, Lopez-LongoGonzalez-Fernandez FJ, ML, Reilly NJ, PJ. Maddison McHugh andfeetArthropathyPA, Evison of in hands G, Turner Woodburn the Characterising DE, clinical J. and biomechanical features of Foot-related al. L, et Davidtz M, Carroll AC, Vandal N, Dalbeth T, Morpeth S, Stewart joint Forefoot J. Dekker APA, Prins JHM, Dekker M, Steultjens M, Leeden der van Accepted Article This by is protectedarticle reserved. Allrights copyright. [45] [44] [43] [42] and sex-matched healthy controls: apilot study.J Foot Ankle Res 2018, 11:38-43. age- with a comparison erythematosus: lupus systemic with people by worn footwear patients with arthritis.Z Med J N 2013;126:70-7. lupus erythematosus: prevalencerisk and J factors. Rheumatol 2014; 41:310-7. Rheumatol 2013;19:367-72.

Stewart S, KeysM, Brenton-Rule AiyerA, A, Dalbeth N, Rome K.Characteristics of for service podiatry new A AE. H, Williams Sahid PJ, A,Gow Ng K, Erikson Rome K, Erdozain VillarJG, I,Nieto J, Ruiz-Irastorza G. Peripheral arterial diseasesystemic in June LV. Scalzi Peripheral vascular RR, disease systemic in patients. J Clinlupus Accepted Article Employment, n(%) Smoker,(%) n egt 16 00) .3(.8 0.30 1.63 (0.08) 74.6(19.5) 1.64 (0.07) 67.3(12.1) Bodyindex, kg/m mass Height, m Weight, kg mmHg 74 Diastolic pressure, blood (10) mmHg 115 pressure, bloodSystolic (14) This by is protectedarticle reserved. Allrights copyright. 0.21 0.97 52(14) 50(93%) Ethnicity, n (%) 48(14) 52(93%) Gender, female, (%) n Age, years N 56 54 Table 1. - Demographic and clinical characteristics and clinical Demographic 2 Retired 5 (9%) Retired 5(9%) Not working 3(5%) Employed 39 (70%) Never(80%) 45 Current 2 (4%) (4%) 2 Current History 9 (16%) 48 41) 28.10 (7.19) 24.87 (4.11) Other 0 (0%) Asian 12 (21%) Pacific(0%) 0 M European(73%) 41 Control SLE ā ori 3 (5%) (5%) 3 ori

(26%) Not working 14 Employed 32(59%) Current 8(15%) History 13 (24%) Never 33 (61%) 76 (9) Asian 13(24%) 5 Pacific (9%) Other 2(4%) 120 (19) M European 31 (57%) ā ori 3 (6%) (6%) 3 ori 0.006 0.006 0.046 0.046 0.31 0.08 0.020 0.020 0.11 0.004 0.004 P Accepted Article This by is protectedarticle reserved. Allrights copyright. (8.1) 2.8 8.2(9.5) (1.1) 0.3 0.7 (1.8) Values are presentedmean (SD) as unless otherwise indicated. Bolded Swollen count joint Tender count joint significant difference at P <0.05. dcto 1% Retired 6 (11%) Education 9 (16%)

Education 2(4%) P values indicate 0.025 0.025 0.001 < Accepted Article This by is protectedarticle reserved. Allrights copyright. L ies uain er 15 (12) tests Laboratory SLE disease duration, years Comorbidities and complications of disease, n (%) n disease, of and complications Comorbidities (%) n Medications, SLEDAI-2K 13.3 Table 2. (9.7) uu ehii 8 (15%) Lupus nephritis Anti-hypertensive 13 Statin 8 5 Anticoagulant Analgesic 17 (24%) NSAID 16 Prednisone 19 35.4 (41.1) 6.8 (10.7) Immunosuppressive 21 (9%) (15%) Hydroxychloroquine 32 (31%) Creatinine, (39%) (30%) ESR, mm/hr (35%) (59%) CRP, mg/L hllis 24 involving(44%); feet 19 (35%) 6 (11%) 21 involving(39%); feet 14 (26%) Chilblains (4%) 2 Sjögren syndrome 4 Fibromyalgia Raynaud’s syndrome disease kidney Chronic (7%) SLE disease characteristics (n = 54) 54) (n = characteristics disease SLE μ mol/L 76.8mol/L (25.8) Accepted Article This by is protectedarticle reserved. Allrights copyright. non-steroidal anti-inflammatory drug. non-steroidal anti-inflammatory drug. erythrocytesedimentation rate;e-GFRestimated = glomerular filtration rate; NSAID = lupuserythematosus disease activity index CRP2000; c-reactive= protein; ESR = Values are presented as mean (SD) unless otherwise indicated. SLEDAI-2K= systemic adoaclrdsae 6 (6%) 1 Diabetes Hypertension 17 Cardiovascular diseases Dyslipidaemia 6 Depression 3 Osteoporosis 7 (2%) (31%) (6%) (6%) (13%) Accepted Article Hallux valgusgrade STJ inversion ROM Ankle lunge Foot posture index This by is protectedarticle reserved. Allrights copyright. 1.78, 11.76 4.58 30(28%) 9(8%) Foot swelling present Dorsiflexion force force Plantarflexion Table 3. present present Foot tenderness ROM dorsiflexion 1MTP Inversion force Inversion STJ eversion ROM otpolmsoe 1. 73 1. 86 50 2.0,8.0 5.0 16.3(8.6) 11.3(7.3) Foot problem score Eversion force b , ° Differences musculoskeletal in footcharacteristics between controlsSLE and b

4. 1.) 09(.) 23 50 . 0.09 -5.0,0.4 -2.3 40.9(9.8) 43.3(10.5) ° , b b 9. 3.) 66(19 -34 -32.3, -14.5 -23.4 66.6(31.9) 90.0(34.9) , N 131(47 78.1(40. 103.1(44.7) N , b b b 170(04 151(32 -20 -47.1, -16.8 -32.0 145.1(53.2) 177.0(60.4) , N 1. 95 1. 82 02 22 . 0.87 2.6 -2.2, 0.2 14.0(8.2) 13.8(9.5) ° , b 3. 1.) 51(33 -. -.,32 0.67 -5.0, 3.2 -0.9 35.1(13.3) 36.0(17.4) ° , b 220(97 189(09 -31 -63.2, -23.1 -43.1 188.9(70.9) 232.0(79.7) N , (13%) Moderate 15 (27%) Mild 30 None 60(54%) 97(57 8. 2.) . -.,74 0.77 -5.5, 7.4 0.9 80.6(22.7) 79.7 (25.7) . 53 56(.) . 0.5,3.2 1.8 5.6(5.1) 3.8 (5.3) 4(3) 7(2) 43 6.41, 32.00 14.32 67(62%) 14 (13%) Control SLE Control Mean (SD) (SD) Mean

N (%) Moderate 8 8 Moderate Mild 18(17%) (72%) None 78 a

SLE

7) -25.0 -36.4, -13.6 0.95 0.57, 1.57 0.84 Diff. OR

Diff. 95% CI for 95% CI for

OR

0.002 <0.001 <0.001 <0.001 0.001 0.009 <0.001 P <0.001

P

Accepted Article 112 feet, SLE =108). This by is protectedarticle reserved. Allrights copyright. 0.93 0.39, 2.77 0.57 0.53 0.27, 2.07 1.04 0.30, 1.86 0.74 values 0.75 14(13%) indicate difference significant at 0.53 0.37, 6.69 0.81 difference between Confidence controlsSLE; CI and = Interval; OR=odds ratio. Bolded 0.68 91(84%) 0.36 6(6%) 14(13%) 0.36, 3.78 0.31, 6.04 0.36, 1.46 1.58 1MTP =first metatarsophalangeal joint; STJ =subtalar joint;rangeof ROM = motion; Diff.= 1.16 1.37 98(88%) 0.72 Hyperkeratotic lesions 9(8%) 3(3%) 27(25%) 5(5%) Claw toes 2(2%) Hammer toes 0(0%) 35(31%) 4(4%) 0(0%) Bony prominence(s) Digital amputation Verruca Tinea b Adjusted for foot pain VAS. foot pain for Adjusted Severe 7 (6%) (7%) (7%) 7 (6%) Severe P <0.05. Severe 2 (2%) a Calculated from number of feet (control = (control offeet number Calculated from P

Accepted Article tplnt,c 6. 12 5. 95 -. -9.1, -3.9 -6.5 This by is protectedarticle reserved. Allrights copyright. 57.2(9.5) 127.6 (20.0) 63.7(102) Stride length, cm Step length, cm Hallux 36.1 154.5( 73.6 (64.2) 56.6 ( Third to fifth metatarsals 50.6 (66.7) 46.4(61.2) Second metatarsal First metatarsal (56.2) Midfoot 25.3 Heel 128.6 (34.9) 68.3(55. 116.1(68.6) 155.4( 244.0(111.0) 64.5 Midfoot Heel kPa pressure, plantar Peak controls and SLE Table 4. Spatiotemporal parameters gait Toes 26.1 (35.7) 60.9 119. 209.3 (90.6) First metatarsal eodmttra 288(0.) 174. 278.8 (104.1) Second metatarsal os 2. 8.) 63.6(89. 124.1(82.6) 127.2( 189.0(100.2) Toes Hallux 235.3 (88. Third to fifth metatarsals Pressure time integral, kPa*s integral, Pressure time Difference in pressureplantar spatiotemporaland gait between parameters

a

a

Control SLE b 58.4) 146.1 (43.6) 89.5 75.8, 103.2 Mean (SD) (SD) Mean ) 4. 6.) 8. -106.9, 65.0 -86.0 149.4(66.9) 8) 176.2 (47.8) 120.4 102.6 87.5, (51.4) 69.8 53.9,117.7 85.6 1. 1.) 1. -18.1, -7.7 -12.9 114.7 (19.1) 7.) 9. -112.0, -68.7 -90.3 0 (70.9) 8.) 147 -129.5, -79.9 -104.7 0 (80.7) 2.)3. 31.1, (26.0) 39.3 47.4 2.)3. 26.3, (28.0) 34.8 43.4 4.)9. 79.3, (42.0) 92.5 105.7 74 8. -115.2, 87.4) -88.6 62.0 53 181 93.8, 122.4 108.1 45.3) 96 6. -85.9, 79.6) -61.8 -37.8 3) -47.8 -64.4, -31.3 3) -60.5 -80.8, -40.1 Diff.

95% CI for Diff.

<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 P

Accepted Article This by is protectedarticle reserved. Allrights copyright. 102. 125.1 (24.5) 0.05, 0.10 0.06, 0.13 0.07 0.01, 0.04 0.10 0.31 (0.09) 0.01,0.03 0.02 Velocity, cm/s 0.73 (0.12) 0.37 0.24 0.42 (0.10)(0.04) 0.02 0.04,0.08 0.64 (0.13) 0.41 (0.04) Double support time, s 0.39 (0.05) 0.06 -0.6, 1.5 0.58(0.08) 0.39 (0.04) Single support time,s 0.5 0.52(0.08) Stance time, s 10.3(3.7) Swing time, s 9.8(4.0) Steps time, Support base,cm VAS. VAS. indicate significant difference at 117.9 (13.5) Cadence, steps/min Diff. = difference between controls SLE; Confidence CI= and Interval. Bolded b Adjusted for VAS. foot Adjusted and BMI pain P < 0.05. a AdjustedBMI, for gait foot velocity and pain 0. 1.) 1. -16.9, -7.6 -12.2 105.7 (10.9) 1.) 2. -31.4, -14.6 -23.0 1 (19.8) P values values <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001

Accepted Article This by is protectedarticle reserved. Allrights copyright. 0.61 -0.05,0.03 VPT (<25mV) Abnormal -0.01 0.44 1.02(0.14) sensation 1.03(0.06) 1.8,6.8 -0.5,1.1 protective Loss of 4.3 0.5 13.2(9.5) 25.2(2.9) 8.9(9.4) 24.9(3.0) ABI Temperature,°C VPT, mV Table 5. 108). bomlAI 9) 3(4) .3 1.03, 9.49 3.13 0.77 13(24%) significant difference at 0.17, 11.30 5(9%) controlsratio.and CI =Confidence Interval; odds Bolded OR SLE; = 1.37 VPT vibration = perception threshold;brachial = ABI ankle index; =differenceDiff. between 1(2%) Abnormal ABI 0(0%) Intermittent claudication Differences neurovascular in foot characteristics between controls and SLE a a P <0.05. 0) 0(% 35 09,1.1 0.05 0.98, 12.91 0.11 3.56 0.75, 6.97 10(9%) 2.89 0 (0%) 10(9%) 3 (3%) Control Control SLE a Calculatednumber from offeet112 feet, = (control = SLE Mean (SD) (SD) Mean

N (%)

SLE

Diff. OR

95% CI for Diff. for CI 95% P 95% CI for values indicate indicate values OR

P

0.001 0.001 0.044 0.044 P

Accepted Article n o an 7(5) 3(0) .5 1.82, 8.15 3.85 14.81 1.58, 43 (40%) 4.84 2.23, 13.40 1.57, 16.14 This by is protectedarticle reserved. Allrights copyright. 17(15%) 5.46 5.03 20(19%) 34 (32%) 1.65, 16 13.06(15%) 4.64 (5%) 5 Any toepain 9(8%) 1(1%) 3.52, 23.12 19 (18%) Posterior heel pain 9.03 1.29, 8.38 Plantar heel pain 2.17, 10.84 3(3%) 3.29 40 (37%) 4.85 Ankle pain 1.10,7.61 5.26 1.13, 2.39 2.93 24 (22%) 7(6%) Medial arch pain 41 (38%) 9(8%) 1.08, 5.88 13(12%) Dorsal midfoot pain 32 (30%) 22(20%) 2.51 17(15%) Plantar pain forefoot (8%) 9 Lesser 25(23%) toe pain 2.24, 8.29 4.31 12(11%) Great toe pain Hallux pain 67 (62%) First MTP pain 32(29%) Any pain foot present 8, 12.6 10.31 11.6 (8.4) 1.3(2.6) living LLTQ of daily activities MFPDI, total mm VAS, Foot pain Table 6. activities recreational LLTQ Difference inself-reported and disabilitypain between SLE and controls

. 2.) 25.7 (23. 4.5 (24.3) 92(.) 47(.) -4.57 34.7 (5.6) 39.2 (1.4) 57(10 2. 62 - 24.9 (6.2) 35.7 (11.0) Control SLE Control Mean (SD) (SD) Mean

N (%) a SLE 9) 21.2 14.6, 27.7

10.79 -14.1, -7.4 Diff. Diff. OR -6.1, -3 95% CI for 95% CI 95% CI for Diff. Diff. OR

<0.001 <0.001 0.006 0.007 <0.001 0.004 <0.001 0.013 <0.001 0.028 0.027 0.034 <0.001 <0.001 <0.001 <0.001 P P Accepted Article = 112 feet, SLE = 108). feet,= SLE= 112 values indicate difference significant at This by is protectedarticle reserved. Allrights copyright. 3.89, 23.50 9.56 3.37, 22.32 8.67 47 (44%) 1.27, 6.01 > Pain 39 (36%) 2.76 9(8%) > Pain 7(6%) 32 (30%) Any rearfoot pain 15(13%) Any pain midfoot Any pain forefoot SLE; ConfidenceCI Interval. = MTP =metatarsophalangeal Ratio. Bolded joint; Odds OR = Index; 5D5L EQ = EuroQol 5 Levels.Dimensions 5 Diff.difference = controls between and Disability - Questionnaire Assessment Health = HAQ-DI Questionnaire; Task Limb Lower VAS = AnalogueVisual MFPDI Scale; Manchester = Foot andPain DisabilityLLTQ Index; = 3 locations 2 locations b b b From either toes, forefoot, midfoot, and/or rearfoot. rearfoot. and/or midfoot, forefoot, toes, From either 3) 2(0) 51 4.11, 46.04 15.18 2.79, 13.42 32 (30%) 6.11 3 (3%) 46 (43%) 12 (11%) P <0.05. a Calculated from number of feet (control (control offeet number Calculated from <0.001 <0.001 0.011 <0.001 <0.001 P