Guidelines for the Management of the Foot Health Problems Associated with Rheumatoid Arthritis Anita E

View metadata, citation and similar papers at core.ac.uk brought to you by CORE

provided by University of Salford Institutional Repository

RESEARCH ARTICLE Guidelines for the Management of the Foot Health Problems Associated with Rheumatoid Arthritis Anita E. Williams, PhD1,7*, Samantha Davies, PGCert in Rheumatology Practice2,7, Andrea Graham, MSc1,7, Abbie Dagg, MSc3,7, Kerry Longrigg, MSc4,7, Caroline Lyons, MSc5,7 & Catherine Bowen, PhD6,7

1Directorate of Prosthetics, Orthotics and Podiatry and the Centre for Health, Sport and Rehabilitation Sciences Research, University of Salford, Salford, UK 2Pennine Acute Hospitals NHS Trust, Manchester, UK 3Wakeﬁeld District Community Healthcare Service, Wakeﬁeld, UK 4East Lancashire Primary Care Trust, Nelson, UK 5NHS Wirral Podiatry Department, Bomborough, UK 6School of Health Sciences, University of Southampton, Southampton, UK 7North West Clinical Effectiveness Group for the Foot in Rheumatic Diseases (Guideline Development Group), University of Salford, Salford, UK

Abstract Background. Rheumatoid arthritis (RA) as a chronic systemic disease, commonly affects the feet, impacting negatively on patients' quality of life. Specialist podiatrists have a prime role to play in the assessment and management of foot and ankle problems within this patient group. However, it has been identified that in many areas there is no specialist podiatry service, with many patients being managed by non‐specialist podiatrists. Therefore, the North West Clinical Effectiveness Group for the Foot in Rheumatic Diseases (NWCEG) identified the need to develop ‘practitioner facing’ guidelines for the management of specific foot health problems associated with RA. Methods. Members of a guideline development group from the NWCEG each reviewed the evidence for specific aspects of the assessment and management of foot problems. Where evidence was lacking, ‘expert opinion’ was obtained from the members of the NWCEG and added as a consensus on current and best practice. An iterative approach was employed, with the results being reviewed and revised by all members of the group and external reviewers before the final guideline document was produced. Results. The management of specific foot problems (callus, nail pathology, ulceration) and the use of specific interventions (foot orthoses, footwear, patient education, steroid injection therapy) are detailed and standards in relation to each are provided. A diagrammatic screening pathway is presented, with the aim of guiding non‐ specialist podiatrists through the complexity of assessing and managing those patients with problems requiring input from a specialist podiatrist and other members of the rheumatology multidisciplinary team. Conclusion. This pragmatic approach ensured that the guidelines were relevant and applicable to current practice as ‘best practice’, based on the available evidence from the literature and consensus expert opinion. These guidelines provide both specialist and non‐specialist podiatrists with the essential and ‘gold standard’ aspects of managing people with RA‐related foot problems. Copyright © 2011 John Wiley & Sons, Ltd.

Keywords Feet; guidelines; rheumatoid arthritis

*Correspondence Anita E. Williams, Brian Blatchford Building ofﬁce PO29, University of Salford, Frederick Road, Salford, M6 6PU, UK. Tel: +44 (0)161 295 7027. Email: [email protected]

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.200

Introduction trained to carry out specific care or treatment, or who can refer them to other specialist care if needed. Rheumatoid arthritis (RA) is a chronic systemic disease Foot health service providers should be aware of that commonly affects the feet (Grondal et al., 2008), indications for urgent referrals, surgical referrals and as Shi et al. (2000) identified, virtually 100% of and disease red flags.’ (Standard 22, page 22) patients report foot problems within 10 years of disease onset. The structural and functional changes in the feet often affect gait and mobility (Turner et al., 2006; Despite evidence for the need of podiatry services Woodburn et al., 2002a; Turner et al., 2006), impacting (Williams and Bowden, 2004) and efforts to ensure that negatively on the patient's quality of life (Otter et al., the recommendations made by NICE (2009) and the fi 2010; Wickman et al., 2004) and speci cally restricting PRCA Standards of Care are met, there are identified the choice of footwear (Goodacre and Candy, 2010; problems with access to podiatry services. The problems Williams et al., 2007, 2010). For some people with RA, identified in both the National Audit Office report the structural changes are a factor in foot ulcer (2009) and the Rheumatology Futures Group report development (Firth et al., 2008), with the risk of (2009) was that podiatry was an underused and under‐ infection, particularly if the patient's medical manage- resourced service and that in many areas there was no ment includes the use of immunosuppressive drugs specialist podiatry service. Limited services were also (Otter et al., 2004; Wilske, 1993). identified by Juarez et al. (2010), who found that in one fi The speci c goals of foot care for the problems district hospital, less than one‐third of RA patients had associated with RA are to relieve pain, maintain access to specialist care. An earlier review of the function and prevent ulceration and infection, thereby provision of foot health services in rheumatology contributing positively to the patient's quality of life departments in the UK (Redmond et al., 2006) found (Woodburn and Helliwell, 1997). These goals can be that only 50% reported adequate basic foot care services achieved with the use of foot health interventions such and less than one in 10 had formal care pathways or as care of the skin and nails, foot orthoses and specialist mechanisms for referral. Interestingly, a fair proportion ‘ ’ therapeutic footwear. The use of foot orthoses and of RA patients access foot care through non‐specialist therapeutic footwear are supported by national guide- routes. Williams and Bowden (2004) identified that lines (Arthritis and Musculoskeletal Alliance [ARMA], 19% of the 139 patients surveyed accessed foot care 2004; National Institute for Clinical Excellence [NICE], through the private sector and 21% were receiving foot 2009), which also recommend that people with RA care at local NHS clinics by non‐specialist podiatrists. should have access to foot health assessment and In support of specialist foot care, the PRCA Standards management early in the disease process. Foot health of Care are ‘patient facing’ in respect of the service that providers, such as podiatrists, have a prime role to play patients with foot problems can expect. However, due to in the assessment and management of foot and ankle the lack of specialist podiatry provision for RA patients, problems within this patient group (NICE, 2009). This there is a need for ‘practitioner facing’ management view is supported by the Podiatry Rheumatic Care guidelines, to provide non‐specialist podiatrists and Association (PRCA) Standards of Care, ARMA (2004) other foot health providers with specific guidance for and the British Society for Rheumatology (BSR) the management of people with RA‐related foot health (Luqmani et al., 2006). They all strongly advocate the problems. Our aims, therefore, were to develop need for a dedicated and specialist podiatry service for ‘practitioner facing’ guidelines on the management of the diagnosis, assessment and management of foot specific foot health problems associated with RA using problems associated with RA, along with periodic review, an evidence‐based approach and consensus of specialist particularly for those patients with high levels of disease podiatrist practitioners. activity. The PRCA (2010) guidelines state that:

Methods ‘People whose condition does not respond to Guideline development treatment, who experience new or worsening symptoms, or whose personal situations change, A guideline development group was formed from should have timely access to health professionals members of the North West Clinical Effectiveness

Group (NWCEG). The group included the Chair of prevent or minimize deformity and reduce the risk of the NWCEG (S.D.), the academic lead for the group ulceration, thereby maintaining or improving the (A.W.), two academics with a podiatry background individuals' independence and overall quality of life. (A.G. and C.B.) and three specialist podiatrists (K.L., Aligned with this philosophy is the fact that podiatrists A.B. and C.L.). Each member of the group took are ideally placed to alert other members of the responsibility for specific aspects of management of the multidisciplinary team (MDT) if the patient's health foot affected by RA: the management of callus, status deteriorates or if other, profession‐specific, management of nail conditions, management of interventions are needed, such as physiotherapy or ulceration, foot orthoses and footwear, steroid injec- occupational therapy. tion therapy, surgery, ultrasonography and patient The guidelines contain specific reference to the role education. of the clinical specialist and both the essential and All relevant available databases were searched (from ‘gold standard’ requirements for a podiatry service. 2000 to 2010), specifically Medline, Embase, the The rationale for identifying both the essential and Cochrane Database and the Cochrane Musculoskeletal gold standard requirements is to contextualize the Group Register. References from all articles identified importance of foot care for this patient group, while from the databases were also hand searched. The terms acknowledging that some services are restricted in ‘rheumatoid arthritis’ and ‘foot’ were combined and relation to advanced resources, such as ultrasonogra- searched in conjunction with the following treatment phy or steroid injection therapy. Further, podiatry terms: ‘treatment’, ‘management’, ‘services’, ‘guide- services that are developing in relation to the lines’, ‘standards of care’, ‘surgery’, ‘ultrasound’, management of people with RA need guidance as to ‘injection therapy’, ‘orthoses’, ‘footwear’, ‘callus’, ‘foot the ideal, ‘gold standard’ resources that could be added ulcers’ and ‘patient education’. as funding becomes available. The evidence was used to inform each section of the The guidelines recommend that a local pathway of initial draft of the guidelines. These were then taken to referral should be in place to facilitate appropriate and the NWCEG for review; where evidence was lacking, timely patient referrals to a specialist podiatrist by any expert opinion was obtained and added to each section member of the podiatry team, the rheumatology MDT, of the guidelines as a consensus of current best practice. primary care team or private practitioner. In the absence Each section was then further developed and edited by of a specialist podiatrist, there is guidance for referral to one member of the guideline group (A.W.) to ensure other members of the rheumatology MDT, so that consistency in presentation and content. This formed patients with complex foot problems, such as ulcera- the second draft of the guidelines, which were sent to tion, receive the right management in relation to their three external reviewers, two consultant rheumatolo- foot and general disease management (see Figure 1). gists and the Chair of the Podiatry Rheumatic Care The aims of the foot screening pathway and a Association. Following feedback from the external primary assessment/annual screening tool (an example reviewers, the final guideline document was produced. of which is in the full guideline document) are to enable identification of those patients who are at risk of Results ulceration or the development of deformity, and to initiate appropriate and timely interventions. In Guideline summary addition, it is recommended that practitioners working The achievement of the group was that a consensus in the private sector make links with local specialist was agreed for all aspects of management for people podiatry services or rheumatology services in order to with RA‐related foot pathology, based on available facilitate timely referral for patients whose foot health evidence and best practice. The guidelines compre- deteriorates. hensively cover all aspects of current foot health A thorough primary assessment, followed by an management in relation to the requirements of a annual review, is essential in managing patients' foot service, referral pathways, management of specific health with the aim of identifying changes in foot conditions and the evaluation of interventions. health and monitoring foot health interventions. The philosophy of podiatry services for people with Despite individual podiatry services having different RA is to relieve pain, maintain function and mobility, arrangements for new and existing patients in both

Foot Screening Pathway for People with RA

Does the patient complain of foot symptoms?

YES FOOT HEALTH EDUCATION ANNUAL REVIEW WITH NO PODIATRIST

FOOT HEALTH ASSESSMENT

SKIN VASCULAR FOOT ACTIVITIES Ulceration (NB FUNCTION NAILS FOOT OF DAILY cellulitis may be Claudication AND GAIT SYMPTOMS STRUCTURE LIVING minimal – Rest pain ASSOCIATED Evidence of indicator of Vasculitis Excessive WITH RA bacterial infection may be Absent pulses pronation infection (need pain) (with hand for antibiotics Pain and / Increasing LIFESTYLE Disease held Doppler) Lack of and/or advise swelling difficulty flare Requirement for stability if patient is on associated with Unhealthy antibiotics, biologic with joints/ everyday lifestyle Generally radiographs Falls therapy) tendons tasks habits e.g. unwell Poor smoking NB Patients on muscle Need for nail Inability to fit Difficulty Weight loss biologic therapy NEUROLOGICAL strength surgery into retail coping with Poor diet require urgent shoes fatigue Fatigue consultant Sensory loss Poor Evidence of Weight loss advice if feet posture fungal Evidence of Signs of ulcerate Reduced infection pressure depression Nerve range of (diagnosed related Evidence of entrapment/ motion from mycology lesions such fungal infection compression results as callus (diagnosed from Increasing mycology results stiffness

SMOKING CESSATION SPECIALIST PODIATRIST

RHEUMATOLOGIST

DIETICIAN ORTHOTIST RHEUMATOLOGY SPECIALIST NURSE

SURGICAL OPINION PHYSIOTHERAPIST OCCUPATIONAL PAIN MANAGEMENT TEAM THERAPIST

NB IN THE ABSENCE OF A SPECIALIST PODIATRIST -

• ADVICE SHOULD BE OBTAINED FROM THE PATIENT’S CONSULTANT AS DENOTED BY A RED LINE • ADVICE SHOULD BE OBTAINED FROM AN ORTHOTIST AS DENOTED BY A BLUE LINE • BLACK LINES DENOTE DIRECT REFERRAL • GREEN LINES DENOTE MULTIDISCIPLINARY WORKING BETWEEN THE CORE RHEUMATOLOGY MULTIDISCIPLINARY TEAM

Figure 1 Foot health screening pathway for people with RA foot‐related problems. This ﬁgure is available in colour online at wileyonlinelibrary.com

Musculoskelet. Care (2011) © 2011 John Wiley & Sons, Ltd. Williams et al. Guidelines for RA‐Related Foot Problems primary and secondary care services and private before debridement is considered. According to Davys practice, an initial foot assessment and screening et al. (2005), debridement of callus over the plantar should be carried out for all patients at the first point metatarsal areas should be carried out with caution, of contact with a podiatrist. particularly over prominences such as those caused by The management of specific foot problems (callus, subluxation of the metatarso‐phalangeal joints, where it nail pathology, ulceration) and the use of specific may be considered to have a protective role. If callus is interventions (foot orthoses, footwear, patient educa- removed, pressure‐relieving insoles or foot orthoses tion, steroid injection therapy) are detailed and should be provided (Davys et al., 2005), in order to standards in relation to each are provided within the protect the foot from the risk of ulceration. Other guidelines. As it was acknowledged by the NWCEG problems involving the skin are fungal infections, which that some foot problems are ideally managed through can also infect the nails. Fungal infections should be collaboration with other members of the rheumatology investigated and treated, as they can lead to ulceration MDT, the guidelines also make recommendations and secondary bacterial infection (Jones, 1997). for referral and collaboration with other members of Although there is no direct evidence of its benefits, the MDT. there was a consensus from the group members that The following are examples of the essential stan- patient education should be delivered as an essential dards of assessment, management and collaboration. component of foot health and general health However, readers should access the full guidelines for management. the details and supporting information for all the guideline standards. Referral and collaboration It was agreed through consensus in the group that Assessment and management of those patients with severe symptoms and/or complica- foot problems tions, plus those with medical management that puts All patients should be evaluated at the initial them at risk of the serious consequences of foot assessment for the need for foot orthoses, footwear infections, should be managed by a specialist podia- advice and, where necessary, therapeutic footwear. The trist. Specialist podiatrists mostly work within the use of foot orthoses and therapeutic footwear are rheumatology MDT or, if not, have clear and defined advocated by NICE (2010) and there is some evidence referral pathways for urgent problems that need to be that supports the use of therapeutic footwear for seen by the rheumatologist. However, some services do reducing pain and improving mobility (Williams et al., not have specialist podiatrists, with many of their 2007) in those with established foot deformity. patients being seen by a generalist podiatrist or by a In the case of early disease, feet should be assessed private practitioner (Williams and Bowden, 2004). It for evidence of abnormal foot function within was felt, therefore, that these practitioners should have 18 months from onset of symptoms, before tarsal clear guidance as to when to refer to a rheumatologist erosions occur (Woodburn et al., 2002a). Functional or other members of the MDT in order to protect the foot orthoses should be provided as soon as possible patient from the severe consequences of foot infections following diagnosis, in order to reduce pain, improve and ulceration. function and maintain alignment of the architecture of A patient's rheumatologist or rheumatology nurse the foot (Woodburn et al., 2002b). must be contacted as a matter of urgency if patients who Steroid injection therapy should be considered for are being managed with biologic therapy develop foot targeting localized, inflamed joints when the general ulceration and infection (Otter et al., 2004). Optimum disease is controlled, but only in the absence of ulcer management for any patient can only be achieved infection (Ward et al., 2008). However, any associated by a holistic and integrated MDT approach (Firth et al., structural deformity should be managed with foot 2008). Further, there was consensus agreement that orthoses in conjunction with steroid injection therapy advice should be taken from the patient's rheumatol- (Helliwell et al., 2006). ogist on the management of infected ingrown nails or if Callus over the plantar metatarsal area should be there is a need for nail surgery, particularly if the assessed in relation to symptoms and causative factors patient's medical management is with biologic therapy.

Other reasons for urgent collaboration include tendon foot problems, in order to maintain and improve their ruptures and septic arthritis, which require immediate foot health, mobility and participation in life activities referral for both medical and surgical management and occupations. (Helliwell et al., 2006).

Acknowledgements Foot health measurement Members of the NWCEG: Susan Cunliffe, Jane The use of foot health measurement tools, such the Humphreys, Rose Hynriw, Gemma Iliadis, Deborah Foot Impact Scale (Helliwell et al., 2005) or the Salford Kirk, Angela Knott, Adrian Leach, Danielle Meadows, Arthritis Foot Evaluation instrument (Walmsley, Sarah Naylor, Elaine Pettigrew, Veronica Potter, 2010), are considered as being a desirable adjunct to Patricia Smith, Suzanne Smith, Julia Stell. clinical practice in order to evaluate the impact of foot External reviewers of the guidelines: Dr Vinodh problems on the individual, but also to provide Devakumar, Dr Neil Snowden, Robert Field (Chair evidence for the level of effectiveness of interventions. PRCA). Further to these measurement tools, the use of musculoskeletal ultrasound is considered a useful REFERENCES method of monitoring foot health, as well as its role in the assessment and diagnosis of specific foot and Arthritis and Musculoskeletal Alliance (2004). Standards ankle pathology (Bowen, 2003). of Care for People with Inflammatory Arthritis. Available at http://www.arma.uk.net Bowen CJ (2003). Extending the scope of practice for Discussion podiatrists: A consideration of the use of diagnostic The aim of these guidelines was to provide all ultrasound imaging. British Journal of Podiatric podiatrists and other foot health providers with Medicine 6: 92–5. pragmatic clinical recommendations for the manage- Davys HJ, Turner DE, Helliwell PS, Conaghan PG, Emery P, ment of RA‐related foot and ankle problems. Woodburn J (2005). Debridement of plantar callosities in rheumatoid arthritis: A randomized controlled trial. The authors acknowledge that there were limitations Rheumatology 44: 207–10. to the approach taken to guideline development, in that Firth J, Helliwell P, Hale C, Hill J, Nelson E (2008). The it was not based on a systematic review of the literature predictors of foot ulceration in patients with rheuma- ‐ and there was no meta analysis of data from the toid arthritis: A preliminary investigation. Clinical available evidence. However, a pragmatic approach was Rheumatology 27: 1423–8. taken, whereby the available evidence was synthesized Goodacre LJ, Candy FJ (2010). ‘If I didn't have RA I with the clinical expertise of the members of the wouldn't give them house room’: The relationship NWCEG. This approach ensured that the guidelines between RA, footwear and clothing choices. Rheuma- were relevant and applicable to current practice as ‘best tology (In press). practice’, based on the available evidence from the Grondal L, Tengstrand B, Nordmark B, Wretenberg P, literature and consensus expert opinion. It was also an Stark A (2008). The foot: Still the most important iterative process in which ‘expert’ external reviewers reason for walking incapacity in rheumatoid arthritis: Distribution of symptomatic joints in 1,000 RA contributed to the final document. patients. Acta Orthopaedica 79: 257–61. Future work will involve the revision of the guidelines Helliwell P, Reay N, Gilworth G, Redmond A, Slade A, biannually, in order to embrace the emerging research Tennant A, Woodburn J (2005). Development of a foot on foot and ankle management in people with RA. impact scale for rheumatoid arthritis. Arthritis and Additionally, the NWCEG is developing an audit tool, Rheumatism 53: 418–22. so that the standards can be mapped against clinical Helliwell P, Woodburn J, Redmond A, Turner D, Davys H practice. (2006). The Foot and Ankle in Rheumatoid Arthritis. A Comprehensive Guide. Edinburgh: Churchill Livingstone. Conclusion Jones CJ (1997). A pharmacological case history of a patient with rheumatoid arthritis with particular These guidelines provide both the essential and ‘gold reference to podiatric practice. Journal of British standard’ aspects of managing people with RA‐related Podiatric Medicine 52: 97–100.

Juarez M, Price E, Collins D, Williamson L (2010). Turner DE, Helliwell PS, Emery P, Woodburn J (2006). Deficiencies in provision of integrated multidisciplinary The impact of rheumatoid arthritis on foot function in podiatry care for patients with inflammatory arthritis: A the early stages of disease: A clinical case series. BMC UK district general hospital experience. The Foot 20: Musculoskeletal Disorders 7: 102. 71–4. Walmsley (2010). Development of a Patient Reported Luqmani R, Hennell S, Estrach C, Birrell F, Bosworth A, Outcome Measure for the Assessment and Evaluation Davenport G, Fokke C, Goodson N, Jefferson P, Lamb E, of the Foot Affected by RA. PhD Thesis, University of MohammedR,OliverS,StablefordZ,WalshD, Salford. Washbrook C, Webb F (2006). British Society for Ward ST, Williams PL, Purkayastha S, (2008). Intra‐ Rheumatology (BSR) and British Health Professionals articular corticosteroid injections in the foot and ankle: A in Rheumatology (BHPR) Guidelines for the man- prospective 1‐year follow‐up investigation. Journal of agement of RA – The first 2 years. Rheumatology 45: Foot and Ankle Surgery 47: 138–44. 1167–9. Wickman AM, Pinzur MS, Kadanoff R, Juknelis D (2004). National Audit Office (2009). Services for people with Health‐related quality of life for patients with rheuma- rheumatoid arthritis. London: HMSO. toid arthritis foot involvement. Foot and Ankle National Institute for Clinical Excellence (2009). Guidance International 25: 19–26. for the management of rheumatoid arthritis in adults. Williams AE, Bowden AP (2004). Meeting the challenge for http://guidance.nice.org.uk/CG79/Guidance/pdf/English foot health in rheumatic diseases. The Foot 14: 154–8. Otter SJ, Young A, Cryer JR (2004). Biologic agents used Williams AE, Rome K, Nester CJ (2007). A clinical trial of to treat rheumatoid arthritis and their relevance to specialist footwear for patients with rheumatoid podiatrists: A practice update. Musculoskeletal Care 2: arthritis. Rheumatology 46: 302–7. 51–9. Williams AE, Nester CJ, Ravey MI, Kottink A, Otter SJ, Lucas K, Springett K, Moore A, Davies K, Cheek L, Morey‐Klapsing G (2010). Women's experiences of Young A, Walker K (2010). Foot pain in rheumatoid wearing therapeutic footwear in three European arthritis prevalence, risk factors and management: an countries. Journal of Foot and Ankle Research 3: 23. epidemiological study. Clinical Rheumatology 29: Wilske KR (1993). Inverting the therapeutic pyramid: 255–71. Observations and recommendations on new directions PRCA (2010). PRCA Standards of Care for People with in rheumatoid arthritis therapy based on the author's Musculoskeletal Foot Health Problems. Available at experience. Seminars in Arthritis and Rheumatism 23: http://www.prcassoc.org.uk/standards‐project (Accessed 11–8. 11 November 2010). Woodburn J, Helliwell P (1997). Foot problems in Redmond AC, Waxman R, Helliwell PS (2006). Provision rheumatology. British Journal of Rheumatology 36: of foot health services in rheumatology in the UK. 932–3. Rheumatology 45: 571–6. Woodburn J, Helliwell PS, Barker S (2002a). Three‐ Rheumatology Futures Group (2009). Perceptions of dimensional kinematics at the ankle joint complex in patients and professionals on rheumatoid arthritis care. rheumatoid arthritis patients with painful valgus London: The King's Fund. deformity of the rearfoot. Rheumatology 41: 1406–12. Shi K, Tomita T, Hayashida K, Owaki H, Ochi T (2000). Woodburn J, Barker S, Helliwell PS (2002b). A randomized Foot deformities in rheumatoid arthritis and relevance controlled trial of foot orthoses in rheumatoid arthritis. of disease severity. Journal of Rheumatology 27: 84–9. Journal of Rheumatology 29: 1377–83.