Foot Health: Managing RA Feet - What to Expect from a Podiatry Service

The problems that people experience with their feet when they have an inflammatory arthritis such as rheumatoid arthritis has often been under reported by the people themselves. But also the foot problems often been overlooked in the past by the health professionals that they're seeing. Whilst there's been significant development in the research relating to foot health issues and rheumatology conditions, and there's also more information available about foot health on resources such as the NRAS website, there continues to be variability in the provision of podiatry that people with inflammatory arthritis can access. Where podiatry is available, people often find difficulty in getting timely care with a level of condition that appropriates clinical needs. In just thinking a little bit more about feet and rheumatoid arthritis, up to 90 percent people with this condition will have associated foot problems in some point during their life. For some people this can be actually the first point where their arthritis because apparent with signs of pain or swelling. And for others, over may be N number of months or n number of years into the condition that they then can develop foot problems. There is however a small group that do not follow foot problems at all. Whilst it's been recognized that foot for some people is the first symptom of their rheumatoid arthritis. Historically, presence of pain experienced by people in the early stages of RA has been reported about 32 percent. However, now we recognize, as this slide shows, that this is a lot higher. And in this study, in a four week period, it shows that 74 percent of people in that time period actually experienced foot problems. The front part of the foot is often involved in the early stages, though in reality, it can be any part of the foot. But as I say, it is the front part that is predominantly the area of initial presentation. This slide shows three elements that make up the arthritis process. And they are inflammation of the synovium, so that's this tissue lining to the joints. And then there's cartilage erosion and repair and bone erosion and repair. And really the characteristic of the arthritis that people have is based on which of these components dominates. And that can vary between individuals. So predominantly, for instance, somebody with inflammatory arthritis such as rheumatoid arthritis, it is synovial inflammation that drives that process. And it is then that that goes on to cause the foot to change shape. Just like to spend a couple of moments thinking about the stages of rheumatoid arthritis and how it affects the foot. We're going to break that down into early rheumatoid foot problems and then established foot problems. When somebody attempts podiatry clinic and they have an early rheumatoid arthritis, there is a general advice that they need and that is around an understanding of their foot and its anatomy, common problems that might occur within the foot associated with rheumatoid arthritis, and how they may manage it themselves. We'd also talk about footwear, may be when it's appropriate to put devices such as orthotics inside the footwear. But also make sure they're aware about the importance of daily foot checks and what to do if they get a break in the skin that may then go on to become infected. We tend to also talk about exercise and level of exercise that's appropriate to them. And also make sure they're aware of how to access the service should they need it. At that stage, the minimum contact they should have with podiatry service would be seen as one year. If in that first appointment we also note through our screening of the foot structures or if they're reporting, say for instance, pain within their forefoot, we would then go on to form a treatment plan to ground that condition. But again, even once that treatment is being carried out they should at least be coming back into service once every year for a review of the care. In reality, it's probably more often. We're going to then look to people who have got more established foot disease that initial advice around when to access the service, what to do if you get a foot problem, all of that still applies. But the emphasis may well change slightly because they may have foot that's changing shape. And with that change in the structure and sometimes the tissues can become vulnerable. And this top slide shows that where the toes are just retracted a little bit, so they've drawn back. And so that's made the plant or the undersurface of the forefoot more vulnerable to pressure and the tissue is thickened as result. So part of the podiatry assessment of an intervention is to maintain that tissue as a viable structure through may be routine care, specialist insoles, and footwear. Also, what we're trying to do is maintain the individual's mobility, at least at a level that'll ideally improve it. These factors are an addition to that initial advice that's given in the early stages of disease. Sometimes we get people presenting with feet that are far more difficult. The bottom left picture shows an extreme example of how the foot can change shape. Fortunately, with new medication that is something that we are seeing less and less of when it's actually more likely for us to seem like the picture above, a foot that is relatively unaffected structurally in terms of change. So that's kind of the structural side of what people often come along and tell us about is concerning them with their feet. The other thing was, they often come along and complain of this actual foot pain. And these are the common words they talk about swelling, or sharp, or stabbing pains, hot-burning pains, throbbing. And these are sort of characteristic descriptions that people give, many people will recognize. The other aspect is how rheumatoid arthritis affects the individual's mobility to do really everyday things. So it can make standing or walking very difficult or climbing stairs. And particularly, when it comes to choice of footwear, people find that often quite difficult. So what can podiatry offer? When it comes to looking at how care is provided, it's sometimes quite useful to have a framework in which we work. And this slide shows the World Health Organizations' international classification of function, disability and health. And this is what they call the Interventions Indication Framework. In the top right-hand corner, you can see a person who's got a hot, throbbing, painful foot. And what that is causing them is it restricting what they can actually do in their everyday lives. In the center of this, you can see there's activity. So the reality is their activity is being limited, which is then stopping them doing what they want to do socially. To the far left, the structure in this instance is the foot which is impaired. So any treatments or interventions by, for instance, podiatrist will be targeting on the whole of that impaired structure which aims to improve the activity level, which then enables the person to participate what they want to do on an everyday basis. Of course, other factors such as their rheumatoid arthritis may go through periods of activity which may in itself impair their ability to do things. Or it may be, they may have issues at work or in the home environment which are also similarly impairing their activity. In terms of podiatry, we're targeting on the whole of that impaired structure. So when somebody comes along to a podiatry appointment, they're going to get asked lots of questions. And it's sometimes useful to kind of think, "Well, why is that happening?" And so just going to give you a little bit of an explanation as to why we do that. We're going to ask you lots of questions about your health. Before we even look at your feet, we'll start to ask you these questions. In terms of your rheumatoid arthritis, it's helpful first to know if you're rheumatoid factor positive or seropositive as it sometimes referred to. That gives us an indication as to whether you might be somebody who has other problems going on in addition to the structural stuff. So for instance, somebody who is seropositive is more likely have vasculitis or some sensory changes in their feet, or more likely to get nodules. It's also helpful for us to know if you have erosive disease or not because if there's erosions around foot joints, those joints will become unstable. Things like your recent inflammatory blood results, so ESR and CRP and the DAS28 score, all will help to give your podiatrist and indication of how active your disease is. So if you have that information, it's useful to take it to the appointment. Finally, really, we do need to know all about all your medication that you might be taking. This gives us an idea not just about some of the issues around particular drugs and how that might impact on your foot health, but it also gives us a clue as to other health issues that you might have. Say for instance, you might have heart disease, or blood pressure issues. Remember, if you're on a biologics drug then it's really quite important to note that that won't be on your repeat prescription. So do make sure that your podiatrist is made aware that you're on biologic drugs. The other aspect of your health that we'll be asking about is what we call comorbidities. So those are associated health issues that you might have. So these revolve for instance heart and peripheral arterial problems, blood pressure and high cholesterol levels, history of diabetes with yourself or immediate family, whether you smoke or not has a big influence in terms not only your heart and your circulation but also in terms of how your arthritis might progress. We'd like to know about other illnesses, operations, and also about falling. And you quite likely will be asked whether you've had a fall in the last 12 months, and if you have, what those circumstance have been. And we know that people with rheumatoid arthritis have incidence of falling very similar to the over-70s. But also people with rheumatoid arthritis may have issues such as osteoporosis that makes them more prone to fractures. So we are quite, we will be asking about those factors partly because then when we look at your foot, we'll be seeing if there's anything within the foot that may be contributing to falling. So then we have to look at the foot. So we've taking the shoes and socks off, we have had a look at your shoes and the layer patterns that they present with. And then, we'll be looking at your foot, in terms of its mechanics, are there any areas that suggest that there is overloading of the tissues associated with the foot function, does the foot shape contribute to any tissue damage. And we'll look higher, and look at the overall shape of the legs and how the legs work when you walk. We'll also take account of the blood supply into your feet and also the return of the blood back to the heart and lungs. Vasculitis is an inflammatory condition involving the blood vessels which is associated with inflammatory arthritis in some cases or can be a condition in its own. And artherosclerosis is about changes in the blood vessels associated with plaque formation. We'll also look at sensation as part of our neurological screening of your feet. We talk about protective sensation, that is, whether an individual has enough sensation so they would know when they injure their foot. So this might be just stepping on something sharp, it might be having something like a small stone inside the shoe. And would they be aware of that, because if they're not, then they're more prone to getting a wound as a result of that minor injury. And they won't know that injury is repeating and gradually building up the problem. So we will use what we call the monofilament which is a piece of nylon which delivers a load to the skin. And if people perceive that, then we know that they have this protective sensation. We might do other neurological tests using vibration, temperature, using reflexes, all this builds a picture of how the nervous system is working within the legs. We'll also maybe check the muscle strength as well and tendon function around that. The other thing that we'll look at is, for instance, what we call and iatrogenic problem. So this may be as a result of injury or you may have had surgery to the foot, all those sort of things, that kind of, starts to build out picture of the foot. When we complete out assessment, there are a number of interventions that might be relevant to the individual's part of their foot health needs. Podiatry assessment itself... So we conclude with a functional assessment of the lower limb. It will also reflect the disease patterns and the risk factors that the individual has. And you can see from earlier, we've actually built up that picture through our questioning and then our examination. We'll be looking at their current footwear and the insoles, but also what activities they carry out on a day-to-day basis. We will look at the tissue viability. But our overall treatment will reflect these goals but also the individual's needs and wishes. Things like footwear also need to be sensitive to the fact that people may be conscious of their appearance. So the type of interventions may be around, for instance, information sessions or one-to-one education, might involve orthotic and footwear provision, more detailed assessment using ultrasound, provision of devices, guided injections, managing wounds and ulcers. Some podiatrists are able to carry out foot surgery, so it maybe accessing foot surgery through a podiatrist or depending on the local arrangements through the orthopedic department. All this is delivered within the framework of best practice guidelines and peer review. All the care that is provided as part of a team approach, and that team approach includes yourself and the patient but also your patient organization such as NRAS. So what can you expect from a podiatry service? I think in terms of documentation, there are two documents to be aware of, and they are the Standards of Care for People with Musculoskeletal Foot Health Problems which were produced between Arthritis and Musculoskeletal Alliance and the Podiatric Rheumatology Care Association, and then the NICE Guidelines for Rheumatoid Arthritis. Between these documents, they outline what care should be provided in terms of foot health services for you as a person with inflammatory arthritis. You should have access for a foot health assessment as soon as possible after being diagnosed with your inflammatory arthritis. You should have appropriate literature to support that and education and self-management programs as appropriate to your needs. Early interventions especially with respect to orthosis and education are important. You should be able to access a range of podiatry services including regular access to foot care based on the needs of your assessment or your ongoing reviews. As important as the first one around being able to access services early after your diagnosis, it's also the principle of having access for an annual foot health review with occasional extra appointments as need be. So that could be indicated, for instance, if your arthritis becomes very active or it could be that you change, for instance, from DMARD to a biologic therapy and you have foot issues that put your foot at risk. Podiatry or chiropody is recognized as the profession primarily providing foot care, and that was according to NICE. Podiatry is part of a team of people that are there to support you, these includes people within your rheumatology department or also your GP practice, your pharmacy, social care, but also your family as well.