Podiatry services for patients with arthritis: an unmet need

Foot problems are extremely common in patients with rheumatoid arthritis (RA). There is ample evidence that foot pain, either alone or as a comorbidity, contributes significantly to disability. Despite the high prevalence of foot disease in RA, this problem is often trivialised or underappreciated. The inequity in foot health provision for patients with rheumatic disorders in New Zealand has recently been highlighted. Expertise in dealing with foot problems is often limited among healthcare professionals, and it has been argued that better integration of podiatric services into rheumatology services would be beneficial. The aim of this paper is to highlight the major issues related to foot care for patients with arthritis and provide key recommendations that should implemented to improve access to podiatric services in New Zealand

Foot Pain, Impairment and Disability in Patients With Acute Gout Flares; A Prospective Observational Study

Objectives: The aim of this study was to evaluate the impact of acute gout on foot pain, impairment and disability. Methods: This prospective observational study recruited 20 patients with acute gout flares. Patients were recruited from emergency departments, hospital wards and rheumatology outpatient clinics throughout Auckland, New Zealand. Patients were recruited at the time of the flare (baseline visit) and then reassessed at a follow-up visit once the acute flare had resolved 6-8 weeks after the initial assessment. Joint counts, C-reactive protein and serum urate were recorded at both visits. General and foot-specific outcome measures were also recorded at each visit including pain visual analogue scale, Health Assessment Questionnaire (HAQ)-II, Lower Limb Tasks Questionnaire, and the Leeds Foot Impact Scale. Results: The foot was affected by acute gout in 14 (70%) patients. Objective measures of joint inflammation including swollen and tender joint counts and C-reactive protein significantly improved at the follow-up visit, compared with the baseline visit. At baseline, high levels of foot pain, impairment and disability were reported. All patient-reported outcome measures of general and foot-specific musculoskeletal function improved at the follow-up visit compared with the baseline visit. However, pain, impairment and disability scores did not entirely normalise after resolution of the acute gout flare. Conclusions: Patients with acute gout flares experience severe foot pain, impairment and disability. These data provide further support for improved management of gout to prevent the consequences of poorly controlled disease

An evaluation of seasonal variations in footwear worn by adults with inflammatory arthritis: a cross-sectional observational study using a web-based survey

Background: Foot problems are common in adults with inflammatory arthritis and therapeutic footwear can be effective in managing arthritic foot problems. Accessing appropriate footwear has been identified as a major barrier, resulting in poor adherence to treatment plans involving footwear. Indeed, previous New Zealand based studies found that many people with rheumatoid arthritis and gout wore inappropriate footwear. However, these studies were conducted in a single teaching hospital during the New Zealand summer therefore the findings may not be representative of footwear styles worn elsewhere in New Zealand, or reflect the potential influence of seasonal climate changes. The aim of the study was to evaluate seasonal variations in footwear habits of people with inflammatory arthritic conditions in New Zealand. Methods: A cross-sectional study design using a web-based survey. The survey questions were designed to elicit demographic and clinical information, features of importance when choosing footwear and seasonal footwear habits, including questions related to the provision of therapeutic footwear/orthoses and footwear experiences. Results: One-hundred and ninety-seven participants responded who were predominantly women of European descent, aged between 46–65 years old, from the North Island of New Zealand. The majority of participants identified with having either rheumatoid arthritis (35%) and/or osteoarthritis (57%) and 68% reported established disease (>5 years duration). 18% of participants had been issued with therapeutic footwear. Walking and athletic shoes were the most frequently reported footwear type worn regardless of the time of year. In the summer, 42% reported wearing sandals most often. Comfort, fit and support were reported most frequently as the footwear features of greatest importance. Many participants reported difficulties with footwear (63%), getting hot feet in the summer (63%) and the need for a sandal which could accommodate a supportive insole (73%). Conclusions: Athletic and walking shoes were the most popular style of footwear reported regardless of seasonal variation. During the summer season people with inflammatory arthritis may wear sandals more frequently in order to accommodate disease-related foot deformity. Healthcare professionals and researchers should consider seasonal variation when recommending appropriate footwear, or conducting footwear studies in people with inflammatory arthritis, to reduce non-adherence to prescribed footwear

Spatiotemporal gait parameters and plantar pressure distribution during barefoot walking in people with gout and asymptomatic hyperuricemia: comparison with healthy individuals with normal serum urate concentrations

Background To identify spatiotemporal gait parameters and plantar pressure distribution during barefoot walking in people with gout and people with asymptomatic hyperuricemia by comparing them to healthy individuals with normal serum urate concentrations. Methods Eighty-seven participants were included: 24 with gout, 29 with asymptomatic hyperuricemia and 34 age- and sex-matched normouricemic control participants. Spatiotemporal parameters of gait were assessed during level barefoot walking using a GAITRite® walkway. Peak plantar pressure and pressure time integrals were recorded using a TekScan MatScan®. Results were adjusted for age and body mass index. Results Compared to normouricemic control participants, participants with gout demonstrated increased step time (P = 0.022) and stance time (P = 0.022), and reduced velocity (P = 0.050). Participants with gout also walked with decreased peak pressure at the heel (P = 0.012) and hallux (P = 0.036) and increased peak pressure (P < 0.001) and pressure time integrals (P = 0.005) at the midfoot. Compared to normouricemic control participants, participants with asymptomatic hyperuricemia demonstrated increased support base (P = 0.002), double support time (P < 0.001) and cadence (P = 0.028) and reduced swing time (P = 0.019) and single support time (P = 0.020) as well as increased pressure at the midfoot (P = 0.013), first metatarsal (P = 0.015) and second metatarsal (P = 0.007). Conclusion During barefoot walking, people with gout walk slower with plantar pressure patterns suggestive of apropulsive and antalgic gait strategies. Individuals with asymptomatic hyperuricemia also demonstrate altered barefoot gait patterns when compared to normouricemic control participants. Clinicians may consider dynamic gait outcomes when assessing and managing foot and lower limb related pain and disability in individuals with gout and asymptomatic hyperuricemia

The first metatarsophalangeal joint in gout: a systematic review and meta analysis

Background: The aim of this review was to qualitatively synthesise studies that have investigated characteristics of the first metatarsophalangeal joint (1st MTP) in gout and to undertake a meta-analysis to estimate the average prevalence of acute 1st MTP arthritis across studies in people with gout. Methods: Studies published in English were included if they involved participants who had a diagnosis of gout and presented original findings relating to the following outcome measures associated with the 1st MTP: epidemiology; clinical features; structural and functional characteristics; and microscopic and imaging features. Results: Forty-five studies were included in the qualitative synthesis. 1st MTP pain was a prominent feature in people with gout. People with 1st MTP gout reported walking- and general-disability. Structural and functional characteristics of 1st MTP gout included hallux valgus, osteoarthritis, and restricted joint motion. Successful crystal aspiration ranged from 81 to 91 % and positive crystal identification via microscopy ranged from 83 to 93 % in patients with a history of 1st MTP gout. Imaging features were common at the 1st MTP including the double contour sign, tophi and erosions. Eleven studies involving 2,325 participants were included in the meta-analysis, providing an estimate of the average prevalence of acute 1st MTP arthritis across studies of 73 % (95 % prediction interval 40–92 %; range 48–97 %; I2 = 93 %). Conclusions: 1st MTP acute arthritis is highly prevalent in people with gout and has a substantial impact on patient-reported pain and disability. Gout affects the structure and function of the 1st MTP. Microscopic and imaging studies have demonstrated crystal deposition and joint damage at the 1st MTP in people with gout

Gait characteristics associated with the foot and ankle in inflammatory arthritis: a systematic review and meta-analysis

Background Gait analysis is increasingly being used to characterise dysfunction of the lower limb and foot in people with inflammatory arthritis (IA). The aim of the systematic review was to evaluate the spatiotemporal, foot and ankle kinematic, kinetic, peak plantar pressure and muscle activity parameters between patients with inflammatory arthritis and healthy controls. Methods An electronic literature search was performed on Medline, CINAHL, SportsDiscus and The Cochrane Library. Methodological quality was assessed using a modified Quality Index. Effect sizes with 95 % confidence intervals (CI) were calculated as the standardised mean difference (SMD). Meta-analysis was conducted if studies were homogenous. Results Thirty six studies with quality ranging from high to low met the inclusion criteria. The majority of studies reported gait parameters in Rheumatoid arthritis (RA). The gait pattern in RA was characterised by decreased walking speed (SMD 95 % CI −1.57, −2.25 to −0.89), decreased cadence (SMD −0.97, −1.49 to −0.45), decreased stride length (SMD −1.66, −1.84 to −1.49), decreased ankle power (SMD −1.36, −1.70 to −1.02), increased double limb support time (SMD 1.03, 0.84 to 1.22), and peak plantar pressures at the forefoot (SMD 1.11, 0.76 to 1.45). Walking velocity was reduced in psoriatic arthritis and gout with no differences in ankylosing spondylitis. No studies have been conducted in polymyalgia rheumatica, systemic sclerosis or systemic lupus erythematosus. Conclusions The review identified the majority of studies reporting gait adaptations in RA, but limited evidence relating to other IA conditions. Poor data reporting, small sample sizes and heterogeneity across IA conditions limit the interpretation of the findings. Future studies may consider a standardised analytical approach to gait analysis that will provide clinicians and researchers with objective evidence of foot function in people with IA

Are foot and ankle characteristics associated with falls in people with rheumatoid arthritis? A prospective study.

OBJECTIVE: To determine whether foot and ankle characteristics are associated with falls in people with rheumatoid arthritis (RA). METHODS: Two hundred and one adults with RA were recruited from rheumatology outpatient clinics in Auckland, New Zealand. Clinical characteristics, common fall risk factors, and foot and ankle variables were measured. Participants were prospectively studied for 12 months, to record the occurrence of falls using falls diaries. Logistic regression analysis identified baseline variables which were independent predictors of falls over the 12 months. RESULTS: Eighty-four (42%) participants fell at least once and 39 (19%) experienced multiple (>1) falls over the 12-month follow-up period. In logistic regression analysis, including age and significant baseline variables in bivariate analysis but not baseline fall history, presence of foot or ankle tender joints (odds ratio (OR) 1.95, P=0.034) and psychotropic medication (OR 2.35, P=0.025) were independent predictors of prospective falls. However, when baseline fall history was included in the analysis, psychotropic medication (OR 2.34, P=0.025) and baseline fall history (over the preceding 12 months) (OR 2.27, P=0.008) were independent predictors of prospective falls. CONCLUSION: Foot and ankle characteristics are not associated with falls in people with RA, independent of prior falls. Enquiry about prior falls and psychotropic medications may assist in identifying patients with RA who are at high risk of future falls. This article is protected by copyright. All rights reserved

The footwear experiences of people wth Gout- a qualitative study

Abstract Background: Footwear is an important concern for people with gout, who often describe difficulty finding suitable footwear. Previous studies have identified footwear as a major concern for people with gout. The aim of this study was to carry out an exploration of the footwear experiences of people with gout. Methods: A qualitative descriptive methodological approach was used for both data collection and analysis. A purposive sampling strategy was adopted with semi-structured interviews conducted, involving 11 participants with gout. Thematic analysis was employed to identify key meanings and patterns within the data. Results: Four key themes derived from interviews included; (1) comfort as a priority, (2) knowing what to buy, (3) knowing what to wear, and (4) challenges of different environments. Footwear comfort was of great importance and linked to characteristics of footwear, with uncomfortable footwear negatively influencing participation in daily activities. The balancing of comfort, appearance and cost, led to less options and reduced confidence when shoe shopping. Footwear use was further limited by the presence of foot tophi and flares, resulting in compromise of footwear choice. Environments such as formal settings and the workplace, led to different footwear requirements. Conclusion: People with gout experience problems with footwear which can impact many aspects of life. Health care professionals should consider these footwear-related issues to help facilitate those with gout in finding appropriate footwear. Keywords: Gout, Footwear, Qualitative researc

Clinically-evident tophi are associated with reduced muscle force in the foot and ankle in people with gout: a cross-sectional study

Background: The foot and ankle represent a common site for tophi in people with gout, yet it is unclear whether the presence of tophi is related to impaired muscle function. This study aimed to determine the association between foot and ankle tophi and muscle force in people with gout. Methods: Participants with gout were stratified into two groups based on the presence of clinically-evident tophi affecting the foot or ankle on physical examination. Isometric muscle force for plantarflexion, dorsiflexion, inversion and eversion was measured using static dynamometry. Mixed-models regression was used to determine the difference in muscle force between the two groups while adjusting for age, disease duration and foot pain. This model was also used to determine the difference in muscle force between presence and absence of tophi at specific locations within the foot and ankle. In addition, Pearson’s correlations were used to determine the association between total foot tophus count and muscle force. Results: Fifty-seven participants were included (22 with foot or ankle tophi and 35 without foot or ankle tophi). Foot and ankle tophi were most often seen at the Achilles tendon. After adjusting for age, disease duration and foot pain, participants with tophi had significantly reduced muscle force during plantarflexion (P < 0.001), dorsiflexion (P = 0.003), inversion (P = 0.003) and eversion (P = 0.001) when compared to participants without tophi. Those with Achilles tophi had significantly reduced force during plantarflexion (P < 0.001), inversion (P = 0.008) and eversion (P = 0.001). No significant differences in muscle force were observed between the presence and absence of tophi at other foot or ankle locations. There were also no significant correlations between total foot tophus count and muscle force (all P > 0.05). Conclusion: In people with gout, clinically-evident foot or ankle tophi are associated with muscle force deficits during foot plantarflexion, dorsiflexion, inversion and eversion, which persist despite adjusting for age, disease duration and foot pain. Tophi at the Achilles tendon, which associate with force deficits, may contribute to reduced muscular activation and consequent disuse muscle atrophy