The Foot and Ankle in Rheumatoid Arthritis

Evaluating care 185 Introducing a quality-of-life measure into clinical This is an area that is still undergoing some devel- practice (adapted from Higginson & Carr 2001) opment and will likely continue to change rapidly in the near future. It also represents an area where some 1. Identify a project leader of the greatest misfit has occurred between main- 2. Review measures in use within and outside your stream rheumatology and those responsible for the foot health of rheumatology patients. It is in the best organization interests of our patients to have at least a common cur- 3. Involve staff and patients rency for communication between the various parties 4. Decide which other outcomes need to be measured involved, and standardized evaluations represent that 5. Choose a measure currency. 6. Pilot test the measure to assess suitability to your own specific purpose* 7. Prepare and test paperwork 8. Train staff as required 9. Set start date and review points 10. Introduce measure 11. Review 12. Modify administration as required* *Note: Before any existing measure is adopted, some thought should be given to copyright issues and to the need for re- validation in a specific clinical population. This applies both to the instrument itself and its mode of administration. References patients with an acute stroke. Scandinavian Journal of Rehabilitation Medicine 1995; 27(1): 27–36. Andresen EM, Rothenberg BM, Panzer R, Katz P and Bergner M, Bobbitt RA, Pollard WE, Martin DP and Gilson McDermott MP Selecting a generic measure of health- BS The Sickness Impact Profile: validation of a health related quality of life for use among older adults. status measure. Medical Care 1976; 19(1): 57–67. A comparison of candidate instruments. Evaluation Boutry N, Larde A, Lapegue F, Solau-Gervais E, and the Health Professions 1988; 21(2): 244–264. Flipo RM and Cotten A Magnetic resonance imaging appearance of the hands and feet in patients with early Barrett EM, Scott DG, Wiles NJ and Symmons DP The rheumatoid arthritis. Journal of Rheumatology 2003; impact of rheumatoid arthritis on employment status in 30(4): 671–679. the early years of disease: a UK community-based study. Bouysset M, Tebib J, Tavernier T, Noel E, Nemoz C, Bonnin Rheumatology 2000; 39(12): 1403–1409. M, Tillmann K and Jalby J Posterior tibial tendon and subtalar joint complex in rheumatoid arthritis: magnetic Beaton DE, Hogg-Johnson S and Bombardier C Evaluating resonance imaging study. Journal of Rheumatology 2003; changes in health status: reliability and responsiveness 30(9): 1951–1954. of five generic health status measures in workers with Bouysset M, Tebib J, Noel E et al. Rheumatoid flat foot and musculoskeletal disorders. Journal of Clinical deformity of the first ray. Journal of Rheumatology 2002; Epidemiology 1997; 50(1): 79–93. 29(5): 903–905. Brazier J, Jones N and Kind P Testing the validity of the Bennett PJ, Patterson C and Dunne MP Health-related quality Euroqol and comparing it with the SF-36 health survey of life following podiatric surgery. Journal of the questionnaire. Quality of Life Research 1993; 2(3): 169–180. American Podiatric Medical Association 1001; 91(4): Brooks R EuroQol: the current state of play. Health Policy 164–173. 1996; 37: 53–72. Budiman-Mak E, Conrad KJ and Roach KE The Foot Bennett PJ, Patterson C, Wearing S and Baglioni T Function Index: a measure of foot pain and disability. Development and validation of a questionnaire designed Journal of Clinical Epidemiology 1991; 44(6): 561–570. to measure foot-health status. Journal of the American Carr A Adult measures of quality of life. Arthritis Care and Podiatric Medical Association 1998; 88(9): 419–428. Research 2003; 49(5): 113–133. Benvenuti F, Ferrucci L, Guralnik JM, Gangemi S and Baroni A Foot pain and disability in older persons: an epidemiologic survey. Journal of the American Geriatrics Society 1995; 43(5): 479–484. Berg K, Wood-Dauphinee S and Williams JI The Balance Scale: reliability assessment with elderly residents and

186 THE FOOT AND ANKLE IN RHEUMATOID ARTHRITIS Carr AJ and Higginson IJ Are quality of life measures Fries J, Spitz P, Kraines R, Guy and Holman H Measurement patient centred? British Medical Journal 2001; 322(7298): of patient outcome in arthritis. Arthritis and Rheumatism 1357–1360. 1980; 23(2): 137–145. Carr AJ, Gibson B and Robinson PG Measuring quality of Garratt A, Schmidt L, Mackintosh A and Fitzpatrick R life: Is quality of life determined by expectations or Quality of life measurement: bibliographic study of experience? British Medical Journal 2001; 322(7296): patient assessed health outcome measures. British 1240–1243. Medical Journal 2002; 324(7351): 1417. Caselli MA, Levitz SJ, Clark N, Lazarus S, Velez Z and Garrow AP, Papageorgiou AC, Silman AJ, Thomas E, Jayson Venegas L Comparison of Viscoped and PORON for MI and Macfarlane GJ Development and validation painful submetatarsal hyperkeratotic lesions. Journal of a questionnaire to assess disabling foot pain. Pain of the American Podiatric Medical Association 1997; 2000; 85(1–2): 107–113. 87(1): 6–10. Geenen R, Jacobs JWG, Godaert G, Kraaimaat FW, Brons Chen J, Devine A, Dick IM, Dhaliwal SS and Prince RL MR, Van der Heide A and Bijlsma JWJ Stability of health Prevalence of lower extremity pain and its association status measurement in rheumatoid arthritis. British with functionality and quality of life in elderly women Journal of Rheumatology 1995; 34(12): 1162–1166. in Australia. Journal of Rheumatology 2003; 30(12): 2689–2693. Goldbach-Mansky R, Woodburn J, Yao L and Lipsky PE Magnetic resonance imaging in the evaluation of bone Dawson J and Carr A Outcomes evaluation in orthopaedics. damage in rheumatoid arthritis: a more precise image Journal of Bone and Joint Surgery – British Volume 2001; or just a more expensive one? Arthritis and Rheumatism 83(3): 313–315. 2003; 48(3): 585–589. de Jong Z, van der Heijde D, McKenna SP and Whalley D Greenhalgh T How to read a paper. Papers that report The reliability and construct validity of the RAQoL: a diagnostic or screening tests. British Medical Journal rheumatoid arthritis-specific quality of life instrument. 1997; 315(7107): 540–543. British Journal of Rheumatology 1997; 36(8): 878–883. Guyton GP Theoretical limitations of the AOFAS scoring Devauchelle Pensec V, Saraux A, Berthelot JM et al. Ability systems: an analysis using Monte Carlo modeling. Foot of foot radiographs to predict rheumatoid arthritis in and Ankle International 2001; 22(10): 779–787. patients with early arthritis. Journal of Rheumatology 2004; 31(1): 66–70. Hawker G, Melfi C, Paul J, Green R and Bombardier C Comparison of a generic (SF-36) and a disease specific Deyo RA, Inui TS, Leininger J and Overman S Physical and (WOMAC) (Western Ontario and McMaster Universities psychosocial function in rheumatoid arthritis. Archives Osteoarthritis Index) instrument in the measurement of of Internal Medicine 1982; 142: 879–882. outcomes after knee replacement surgery. Journal of Rheumatology 1995; 22(6): 1193–1196. Doward LC, Meads DM and Thorsen H Requirements for quality of life instruments in clinical research. Value in Helliwell P, Allen N, Gilworth G, Redmond A, Slade A Health 2004; 7(Suppl.1): S13–S16. and Tennant A Development of a foot impact scale for rheumatoid arthritis. Arthritis Care Research 2005: 53(3): Drossaers-Bakker KW, Kroon HM, Zwinderman AH, 418–422. Breedveld FC and Hazes JM Radiographic damage of large joints in long-term rheumatoid arthritis and Helliwell PS Lessons to be learned: review of a its relation to function. Rheumatology 2000; 39(9): multidisciplinary foot clinic in rheumatology. 998–1003. Rheumatology 2003; 42(11): 1426–1427. Escalante A, Haas R and Del Rincon I Measurement Hewlett S, Smith AP and Kirwan JR Measuring the meaning of global functional performance in patients with of disability in rheumatoid arthritis: The personal impact rheumatoid arthritis using rheumatology function tests. Health Assessment Questionnaire (PI HAQ). Annals of Arthritis Research and Therapy 2004; 6: 315–325. the Rheumatic Diseases 2002; 61(11): 986–993. Essink-Bot ML, Krabbe PF, Bonsel GJ and Aaronson NK Higginson IJ and Carr AJ Measuring quality of life: Using An empirical comparison of four generic health status quality of life measures in the clinical setting. British measures. The Nottingham Health Profile, the Medical Medical Journal 2001; 322(7297): 1297–1300. Outcomes Study 36-item Short-Form Health Survey, the COOP/WONCA charts, and the EuroQol instrument. Hochberg MC, Chang RW, Dwosh I, Lindsey S, Pincus T Medical Care 1997; 35(5): 522–537. and Wolfe F The American College of Rheumatology 1991 revised criteria for the classification of global Felson DT, Anderson JJ, Boers M et al. The American functional status in rheumatoid arthritis. Arthritis and College of Rheumatology preliminary core set of disease Rheumatism 1992; 35(5): 498–502. activity measures for rheumatoid arthritis clinical trials. The Committee on Outcome Measures in Rheumatoid Hurst NP, Jobanputra P, Hunter M, Lambert M, Lochhead A Arthritis Clinical Trials. Arthritis and Rheumatism 1993; and Brown H Validity of Euroqol – a generic health 36(6): 729–740. status instrument – in patients with rheumatoid arthritis. Economic and Health Outcomes Research Group. British Felson DT, Anderson JJ, Boers M et al. American College Journal of Rheumatology 1994; 33(7): 655–662. of Rheumatology. Preliminary definition of improvement in rheumatoid arthritis. Arthritis and Rheumatism 1995; Jenkinson C, Wright L and Coulter A Criterion validity and 38(6): 727–735. reliability of the SF-36 in a population sample. Quality of Life Research 1994; 3(1): 7–12.

Evaluating care 187 Katz PP, Pasch LA and Wong B Development of an McKenna SP, Doward LC, Niero M and Erdman R instrument to measure disability in parenting activity Development of needs-based quality of life instruments. among women with rheumatoid arthritis. Arthritis and Value in Health 2004; 7(Suppl. 1): S17–S21. Rheumatism 2003; 48(4): 935–943. Meenan R, Gertman PM and Mason JH Measuring Keenan MA, Peabody TD, Gronley JK and Perry J Valgus health status in arthritis: the arthritis impact deformities of the feet and characteristics of gait in measurement scales. Arthritis and Rheumatism 1980; patients who have rheumatoid arthritis. Journal of Bone 23(2): 146–152. and Joint Surgery 1991; 73(2): 237–247. Ostergaard M and Szkudlarek M Imaging in rheumatoid Kind P, Dolan P, Gudex C and Williams A Variations in arthritis – Why MRI and ultrasonography can no longer population health status: results from a United Kingdom be ignored. Scandinavian Journal of Rheumatology 2003; national questionnaire survey. British Medical Journal 32(2): 63–73. 1998; 316(7133): 736–741. Ostergaard M and Wiell C Ultrasonography in rheumatoid Kirwan JR and Reeback JS Stanford Health Assessment arthritis: a very promising method still needing more Questionnaire modified to assess disability in British validation. Current Opinion in Rheumatology 2004; patients with rheumatoid arthritis. British Journal of 16(3): 223–230. Rheumatology 1986; 25(2): 206–209. Paulus HE, Ramos B, Wong WK, Ahmed A, Bulpitt K, Park Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson G, Sterz M and Clements P Equivalence of the acute MS and Sanders M Clinical rating systems for the ankle- phase reactants C-reactive protein, plasma viscosity, hindfoot, midfoot, hallux, and lesser toes. Foot and and Westergren erythrocyte sedimentation rate when Ankle International 1994; 15(7): 349–353. used to calculate American College of Rheumatology 20% improvement criteria or the Disease Activity Score Kuyvenhoven MM, Gorter KJ, Zuithoff P, Budiman-Mak E, in patients with early rheumatoid arthritis. Western Conrad KJ and Post MW The foot function index with Consortium of Practicing Rheumatologists. Journal of verbal rating scales (FFI-5pt): A clinimetric evaluation Rheumatology 1999; 26(11): 2324–2331. and comparison with the original FFI. Journal of Rheumatology 2002; 29(5): 1023–1028. Plant MJ, Saklatvala J, Borg AA, Jones PW and Dawes PT Measurement and prediction of radiological progression Landorf KB and Keenan AM An evaluation of two foot- in early rheumatoid arthritis. Journal of Rheumatology specific, health-related quality-of-life measuring 1994; 21(10): 1808–1813. instruments. Foot and Ankle International 2002; 23(6): 538–546. Platto MJ, OConnell PG, Hicks JE and Gerber LH. The relationship of pain and deformity of the rheumatoid Lane SK and Gravel JW Jr Clinical utility of common serum foot to gait and an index of functional ambulation. rheumatologic tests. American Family Physician 2002; Journal of Rheumatology 1991; 18(1): 38–43. 65(6): 1073–1080. Prevoo ML, van t Hof MA, Kuper HH, van Leeuwen MA, Larsen A, Dale K and Eek M Radiographic evaluation of van de Putte LB and van Riel PL Modified disease rheumatoid arthritis and related conditions by standard activity scores that include twenty-eight-joint counts. reference films. Acta Radiologica Diagnosis 1977; 18(4): Development and validation in a prospective 481–491. longitudinal study of patients with rheumatoid arthritis. Arthritis and Rheumatism 1995; 38(1): 44–48. Leeb BF, Weber K and Smolen JS Rheumatoid arthritis. Diagnosis and screening. Disease Management and Redmond A and Keenan A Understanding statistics: putting Health Outcomes 1998; 4(6): 315–324. p values into perspective. Journal of the American Podiatric Medical Association 2002; 92(5): 115–122. Lopez-Ben R, Bernreuter WK, Moreland LW and Alarcon GS Ultrasound detection of bone erosions in Redmond A, Keenan AM and Landorf KB Horses for rheumatoid arthritis: A comparison to routine courses: the differences between quantitative and radiographs of the hands and feet. Skeletal Radiology qualitative approaches to research. Journal of the 2004; 33(2): 80–84. American Podiatric Medical Association 2002; 92(3): 159–169. Macran S, Kind P, Collingwood J, Hull R, McDonald I and Parkinson L Evaluating podiatry services: testing a Ritchie DM, Boyle JA, McInnes JM, Jasani MK, Dalakos TG, treatment specific measure of health status. Quality of Grieveson P and Buchanan WW Clinical studies with an Life Research 2003; 12(2): 177–88. articular index for the assessment of joint tenderness in patients with rheumatoid arthritis. Quarterly Journal of McCallum J The SF-36 in an Australian sample: validating Medicine 1968; 37(147): 393–406. a new, generic health status measure. Australian Journal of Public Health 1995; 19(2): 160–166. Saag KG, Saltzman CL, Brown CK and Budiman-Mak E The foot function index for measuring rheumatoid McHorney CA, Kosinski M and Ware JE Comparisons of arthritis pain: Evaluating side-to-side reliability. Foot and the costs and quality of norms for the SF-36 health Ankle International 1996; 17(8): 506–510. survey collected by mail versus telephone interview: results from a national survey. Medical Care 1994; 32(6): Scott DL Prognostic factors in early rheumatoid arthritis. 551–567. Rheumatology 2000; 39(Suppl 1): 24–29. McKenna SP and Doward LC The needs-based approach Shadbolt B, McCallum J and Singh M Health outcomes by to quality of life assessment. Value in Health 2004; self-report: validity of the SF-36 among Australian 7(Suppl. 1): S1–S3.

188 THE FOOT AND ANKLE IN RHEUMATOID ARTHRITIS hospital patients. Quality of Life Research 1997; 6(4): rheumatoid arthritis: first step in the development of a 343–352. disease activity score. Annals of the Rheumatic Diseases Sharp JT, Young DY, Bluhm GB et al. How many joints in 1990; 49(11): 916–920. the hands and wrists should be included in a score of van Gestel AM, Haagsma CJ and van Riel PL Validation of radiologic abnormalities used to assess rheumatoid rheumatoid arthritis improvement criteria that include arthritis? Arthritis and Rheumatism 1985; 28(12): simplified joint counts. Arthritis and Rheumatism 1998; 1326–1335. 41(10): 1845–1850. Stucki G, Ewert T and Cieza A Value and application of the van Knippenberg FC and de Haes JC Measuring the quality ICF in rehabilitation medicine. Disability and of life of cancer patients: psychometric properties of Rehabilitation 2003; 25(11–12): 628–634. instruments. Journal of Clinical Epidemiology 1988; Tennant A, McKenna SP and Hagell P Application of Rasch 41(11): 1043–1053. analysis in the development and application of quality Ware J, Snow KK, Kosinski M and Gandek B SF-36 Health of life instruments. Value in Health 2004; 7(Suppl. 1): Survey. Manual and interpretation guide. Boston Health S22–S26. Institute, New England Medical Center, Boston, 1993. Tennant A, Hillman M, Fear J, Pickering A and Chamberlain Weishaupt D, Schweitzer ME, Alam F, Karasick D and Wapner MA Are we making the most of the Stanford Health K MR imaging of inflammatory joint diseases of the foot Assessment Questionnaire? British Journal of and ankle. Skeletal Radiology 1999; 28(12): 663–669. Rheumatology 1996; 35(6): 574–8. Wiles NJ, Scott DG, Barrett EM et al. Benchmarking: the five The Euroqol Group EuroQol: a new facility for the year outcome of rheumatoid arthritis assessed using a measurement of health related quality of life. Health pain score, the Health Assessment Questionnaire, and Policy 1990; 16(3): 199–208. the Short Form-36 (SF-36) in a community and a clinic Tijhuis GJ, de Jong Z, Zwinderman AH, Zuijderduin WM, based sample. Annals of the Rheumatic Diseases 2001; Jansen LM, Hazes JM and Vliet Vlieland TP The validity of 60(10): 956–961. the Rheumatoid Arthritis Quality of Life (RAQoL) Wolfe F Comparative usefulness of C-reactive protein and questionnaire. Rheumatology 2001; 40(10): 1112–1119. erythrocyte sedimentation rate in patients with Tugwell P, Bombardier C, Buchanan WW, Goldsmith CH, rheumatoid arthritis. Journal of Rheumatology 1997; Grace E and Hanna B The MACTAR Patient Preference 24(8): 1477–1485. Disability Questionnaire – an individualized functional Wolfe F and Cathey M. The assessment and prediction priority approach for assessing improvement in of functional disability in rheumatoid arthritis. Journal physical disability in clinical trials in rheumatoid of Rheumatology 1991; 18(9): 1298–1306. arthritis. Journal of Rheumatology 1987; 14(3): 446–451. Wolfe F and Pincus T Listening to the patient: a practical van der Heijde DM, van t Hof MA, van Riel PL et al. guide to self-report questionnaires in clinical care. Judging disease activity in clinical practice in Arthritis and Rheumatism 1999; 42(9): 1797–1808.

189 Chapter 9 Organizing care CHAPTER STRUCTURE FOOT HEALTH AND MEDICAL SERVICES Foot health and medical services 189 There is a large gap between need for foot health serv- Models of care: getting the timing of treatment ices in the UK and their provision (Salvage 1999). Foot pain is highly prevalent and foot-care services have right 192 long been underfunded. As a result of the gap Service provision 194 between needs and service provision, many people Working in a multidisciplinary team 197 have to make-do; approximately one in ten people A multidisciplinary model of care 198 with foot pain simply live with it and do nothing, Summary 202 while a further 40% self-manage their painful foot problems independently (Gorter et al. 2001). It is also known that foot problems are substantially under- reported (Gorter et al. 2000, Munro & Steele 1998), and the dearth of accurate and objective figures makes planning and evaluation of foot health services especially difficult. Only one-quarter of those needing foot health serv- ices have adequate access to NHS services (White & Mulley 1989) and while the private sector takes up some of the shortfall in public sector provision, between 30 and 40% of people needing access to foot- care services still lack access to services of any sort (Garrow et al. 2004, Harvey et al. 1997). The discrep- ancy is greater still in the rheumatology population, with a recent survey of 139 patients attending rheumatology outpatients at a North of England hospital, finding that 89% of this group of patients had foot problems (Williams & Bowden 2004). The inequity in foot health provision to patients with rheu- matic disorders has been noted by both rheumatolo- gists and podiatrists (Helliwell 2003, Michelson et al. 1994, Otter 2004). The foot-health needs for people with rheumatoid arthritis (RA) are highly variable, ranging from no problems or minor demands (such as a need for assis- tance with foot hygiene or nail care) to a need for expert management of significant structural change or

190 THE FOOT AND ANKLE IN RHEUMATOID ARTHRITIS high-risk vasculitic lesions (Helliwell 2003, Korda & Summary of the Department of Health Long Balint 2004). Term Conditions Policy—cont’d At the milder end of the spectrum there is consider- ● Patients can be stratified according to need: able scope for patient self-management (Wagner 2000), Level 3. Case management for complex needs and many patients can safely rely on self-directed home Level 2. Disease specific care remedies, over-the-counter medications or alternative Level 1. Supported self-care therapies. Some will self-manage entirely outside of the umbrella of the formal health-care system, or self-help ● Prioritize resources to highly intensive users of services approaches can be used to supplement patient’s main- ● Establish community-based multidisciplinary teams stream medical care. The potential for self-reliance can ● Develop a local strategy to support self-care. lead to a positive situation where, with careful direction and appropriate supervision, the patient can be placed CONTEXTUAL LINKS at the centre of the management of the disease process National Service Frameworks for Older People and their foot problems (Waxman et al. 2003) and this National Service Frameworks for Long Term Conditions shift in emphasis is in line with current health policy ARMA Standards of Care (ARMA 2004, Department of Health 2004, 2005). Department of Health Musculoskeletal Services Conversely, care must be taken not to leave patients Framework ‘A joint responsibility: doing it differently’ isolated, or lacking the knowledge required for them National Primary Care Development Team (NPCDT) to participate in the process safely. National Primary Care Collaborative (NPCC) National Primary and Care Trust initiative (NATPACT) Foot health services in rheumatology can be pro- vided at a range of levels: from ‘zero-level’ care, where KEY ACTIONS FOR IMPLEMENTATION the patient can successfully and safely self-manage; GENERAL through primary and secondary care; to teaching hos- pital tertiary care requiring a skilled multidisciplinary Group patients according to need team. This philosophy articulates well with latest Establish available services and needs gaps Chronic Disease Management (CDM) and Long Term Involve patients and carers Conditions Policy (Department of Health 2004, 2005). Establish workforce development programme This chapter focuses on services for the majority of LEVEL 3 patients with RA who will have entered the health- Identify patients with complex needs Liaise with community matrons/relevant specialists Summary of the Department of Health Long Plan integrated service Term Conditions Policy LEVEL 2 FULL TITLE Develop multi-professional teams Supporting people with long-term conditions. An Identify patients needing disease management NHS and Social Care Model to support local innova- Create mechanisms for recall/review of patients as tion and integration (ref 264799). appropriate STATUS LEVEL 1 Policy statement – complements and extends imple- Develop strategy to support self-care mentation of the National Service Frameworks for Educate people to better manage themselves Long Term Conditions and Older People. Use local strategic partnerships. PURPOSE care system early in the disease process, at least at the ● To reduce the reliance on secondary care services, level of primary care. It will not tackle the broader issues of patient access to medical diagnosis or more and increase the provision of care in a primary, general public health matters, but will focus on access community or home environment. to adequate foot health services for those who already ● To personalize the care of patients with long-term have a diagnosis. It must be noted, however, that conditions while we will assume, for simplicity’s sake, that such patients have had adequate access to medical services, KEY ASPECTS OF THE MODEL ● Patients with long-term conditions should be identified

Organizing care 191 the level of foot care input will be highly variable, and by legacy systems carried over from decades past. The many patients may, in the context of their foot health priority groupings of the 1960s and 70s, where the at least, be essentially operating outside the health- emphasis was on care for the over 65s, people with care system, despite receiving direct medical interven- diabetes or people taking anticoagulants, should in tion for their rheumatoid disease. theory have long been consigned to history (Muir- Gray 1994). In many UK NHS trusts the performance Many patients with rheumatoid arthritis in the UK indicators for successful foot health services still are monitored on a regular basis in the primary-care emphasize numbers of contacts over quality of service setting by their own general practitioner (GP), and and case-mix, and the old priority groups still exert an those that do not have formal arrangements for influence on the culture if no longer on formal policy shared care will still see their GP on average, some six (Salvage 1999). or seven times a year (Helliwell & O’Hara 1995, Memel & Kirwan 1999). With the advent of GPs with The tension between the breadth of knowledge Special Interests (GPwSIs), increasing development of required for general practice and the specialism formal shared-care arrangements with hospital required for dedicated rheumatology has already specialists, and explicit policy directives such as the been noted for GPs, but the same issue can also create Chronic Disease Management/Long Term Conditions skill-mix and training issues for departments Programme, the emphasis has shifted further towards attempting to serve the foot health needs of patients primary care in recent years and continues to be with RA in primary care. Were comprehensive foot encouraged (ARMA 2004, Department of Health 2004, health services to be made available to all patients Hewlett et al. 2000). In the UK NHS model, the GP is with RA within the existing NHS climate, there regarded as the gatekeeper to other services and so is would be a significant shortfall in suitably trained usually the main entry point to foot health services for and experienced personnel. As the importance of the RA patient. The increasing focus on primary care good foot care in rheumatology becomes an increas- has potential benefits for patients in that this is where ingly high profile issue, it is essential that training, most foot health services have been delivered histori- specialization and career path shortcomings are cally, and it should ensure that services are available addressed. The NHS re-grading exercise offers some to the patient within their own community. The GP is opportunities, as does the advent of Extended Scope also well placed to ensure that foot health services in Practitioner (ESP) roles for AHPs, and the AHP primary care are articulated with any other disci- consultant posts (Carr 2001), moves that are being plines that may be involved in the person’s overall supported to some degree by government-backed health care (Helliwell & O’Hara 1995, Memel & initiatives (HEFCE 2001, NATPACT 2003). It is impor- Kirwan 1999). In practice, however, there are some tant now that the relevant professions, and especially barriers to this ideal. Firstly, it has been suggested that podiatry, act strategically to ensure that as the in a medically complex disease such as RA, the train- demand for disease specific foot care grows the ing and/or skills of GPs may not prepare them ade- professions are able to meet it (Salvage 1999). quately to direct the complex web of services often required by people with RA (Akesson et al. 2003, The increasing role of Primary Care Trusts (PCTs) Badley 1994). This is compounded by an often limited offers considerable potential for purchaser/commis- understanding of foot problems (Gorter et al. 2001), sioners to direct services more specifically toward and of the scope and capacities of podiatrists and patients in most need, and to ensure that funding flows other AHPs in providing foot care for people with RA to support those services that best address the needs of (Memel & Kirwan 1999). To add a further layer of dif- patients. Few PCTs claim to have adequate funds to ficulty there are currently no widely accepted formal meet existing obligations, however, and in the absence assessment and referral pathways for foot problems of strong data for the clinical effectiveness of foot and their related services in rheumatology patients, health services in rheumatology, engendering support and so arrangements that do exist tend to be ad hoc for new and innovative services is not easy. There is a and informal in nature (Redmond et al. 2005). As a growing body of evidence for the merits of good foot result, even where excellent foot health services are care in rheumatology (Crawford & Thomson 2003, available, a GP may not have adequate awareness of Woodburn et al. 2002, 2003), and again there is a patient need, practitioner scope or service availability compelling case that a strategic approach on behalf of to direct patients toward them (Akesson et al. 2003, the relevant professions to present summaries of avail- Korda & Balint 2004). able evidence to policy makers, will help substantiate calls for extended services. This requirement is increas- The actual provision of foot health/podiatry/chi- ingly being included in formal strategy-making ropody services can be disadvantaged in primary care (NATPACT 2003).

192 THE FOOT AND ANKLE IN RHEUMATOID ARTHRITIS KEY POINTS Level 3 : High complexity ● Most people with RA have extensive foot health Case management needs. Level 2 : ● Rheumatology foot health service provision is High risk patchy in the UK. Disease/Care management ● Care of people with long term conditions is increasingly moving into primary care settings. ● Better integration of rheumatology into primary care presents opportunities for better integration of foot health services. MODELS OF CARE: GETTING THE TIMING Level 1 : OF TREATMENT RIGHT 70%−80% of people with LTCs Self care support/ management In providing care for people with foot problems arising from RA it is essential that the full range of Figure 9.1 The Kaiser Permanente Triangle underpinning the medical and patient-related factors, both systemic and Department of Health, Long Term Conditions model. local, are considered, and factored into the way that the service is provided. This represents a considerable cially true when new policy is being launched. We are challenge because a high-quality rheumatology foot also mindful that the details of how a rheumatology health service cannot be a single homogenous entity, foot health service can be implemented will be but must be a complex, multi-layered service capable strongly influenced by local factors such as the loca- of adapting to the changing needs of its patients as tion of the foot health service in primary, intermediate they pass through stages of the disease process. or secondary care settings; the financial resources and staff available; and parallel services provided locally Good service planning recognizes that the needs of by other disciplines. The following section is thus the patient will vary over the course of a life-long dis- intended to provide some governing principles to be ease such as RA, and tailors the services required to adapted to local needs depending on the precise polit- address those needs as they change during the disease ical climate. course (ARMA 2004). This adaptive model of service provision is known in rheumatology as the disease Disease staged management: early disease staged approach, and fits well with the Department of Health’s own Chronic Disease Management and Long There are two main priorities for a foot health service Term Conditions models (Department of Health 2004, providing for patients with early RA: minimizing 2005) (see Fig. 9.1). Using a disease staged approach, future joint damage (deformity), and encouraging and the type of treatments provided, skill-mix, case-mix enabling patient self-management. This early stage of and location of service can be adjusted to best suit the rheumatoid disease is particularly suited to the first needs of a given stage. Timing of services to disease two levels in the Department of Health’s Long Term stages is crucial to the patient, as outcomes can be Conditions model: level one, supported self-care, and influenced significantly. Furthermore, getting the level two, disease-specific care. timing right fits better with government policy and also allows service planners to maximize their use of There is a growing body of evidence that these fac- resources, prioritizing staff, time and physical assets to tors may be fairly successfully managed by a combi- those activities most suited to the needs of the patient nation of medical and local foot health services. The at a given disease stage. new ARMA standards of care make a recommendation that patients with a new diagnosis of RA are referred Some principles suggesting how a responsive for a baseline assessment of foot health needs (ARMA disease-staged rheumatology foot-health service can 2004). Early medical intervention and new forms of be organized are provided in the rest of this section. therapy are proving remarkably successful in manag- We have provided principles rather than a definitive ing the systemic effects of early arthritis, with early model here because in the absence of a widely suppression of inflammatory process leading to accepted or well validated model it would be inappro- priate to make firm recommendations. This is espe-

Organizing care 193 reduced rates of joint damage and bony change such patients with newly diagnosed RA to be simply over- as erosions (Breedveld et al. 2004, Emery & Seto 2003). whelmed by the amount of information that they are Suppression of inflammation also leads to reduction of given (Hill 2003), and to receive uncoordinated and impairments and so less limitation of activity or sometimes conflicting information from too many restriction of participation in life roles. The foot partic- sources. The maturation of this field is leading to ularly, is often involved early in RA (Devauchelle- recognition that, much as the disease needs to be Pensec et al. 2002) and so good systemic management managed according to stage, so does the provision of has a positive effect on the degree of involvement of health promotion information. Again, more work the foot in the early disease process. needs to be done to establish optimum timings, but it would seem sensible that foot-health education is Minimizing the effects in the foot of soft tissue and undertaken in the period after the patient has had joint involvement can greatly improve the health sta- time to reflect on the initial diagnosis, but before the tus of patients with early RA, maximizing mobility foot problems become irreversible. and maintaining many of the physical capacities of people who are often still physically quite able and Disease staged management: established leading active and demanding lives (Woodburn et al. disease 2002). The practical application of local therapies will usually be directed towards off loading strategies, par- In this intermediate stage, foot health activities are still ticularly in the forefoot (Hodge et al. 1999, Woodburn directed at minimizing progressive change and palliat- et al. 2002, 2003). ing symptoms, but the implications of the progression of joint degeneration and structural change become a In the rearfoot, evidence is also accumulating that greater consideration. For service planning, level 1 care there are long-term benefits associated with early is increasingly supplanted by level 2 care aimed at the orthotic therapy in RA (Woodburn et al. 2003). The disease process. The priorities start to shift towards progressive valgus deformity often seen in later dis- broader outcomes such as maintaining employment or ease seems to respond well to early intervention, with active participation in family roles (Backman et al. 2004, both the associated symptoms and rate of progression Young et al. 2000). In turn, proactive, preventative treat- positively influenced by orthotic therapy. Work still ment approaches will increasingly be supplemented by needs to be done to establish whether there is an eco- more reactive, accommodative or palliative interven- nomic case for providing orthoses prophylactically for tions. Orthotic interventions will move away from all new cases of RA, and to determine the types of rigid, controlling devices towards hybrid orthoses approaches that might be most appropriate, but even offering a mix of control and support. Footwear advice based on the current levels of evidence a fairly pro- may become more relevant as the disease becomes active approach can be justified. established, when structural change starts to limit the suitability of retail footwear (Williams & Bowden 2004). The second priority in early arthritis is to encour- During this stage the development of secondary fea- age patients to take some responsibility for managing tures such as areas of raised plantar pressure or the appropriate aspects of their disease. This is proving onset of digital deformity may lead to discomfort, or to be a more contentious area in rheumatology than they may lead to the formation of secondary lesions might initially be expected, however, as the theoreti- such as corns or callus (Williams & Bowden 2004). Full cal appeal of health promotion and self-management podiatry services may be required to supplement basic education appears to translate less well into practical foot care, and insole or padding provision may become results than would be hoped (Helliwell et al. 1999, more relevant. It is also during this stage that some of Hill 2003, Hill 2001). In a culture where patient the more demanding complications become manifest. empowerment is becoming more important, increas- A comprehensive rheumatology foot health service will ing reliance on health promotion has been advocated be able to address problems such as vasculitis, ulcera- by both clinicians and policymakers. The rationale tion and neuropathy as they arise in more severe for this is that patients equipped with the necessary disease (Cawley 1987). In the established phase of the information can make informed decisions about their disease, management is often anchored in secondary disease, its treatment, and their lifestyles, and so care (in level 2: ‘Disease based management’ in the participate more equally with clinical staff in the Kaiser Permanente Triangle in Fig. 9.1) and the change management of their disease. This approach appears in this emphasis described in the Long Term Conditions to fail, however, if there is inadequate recognition of strategy (Department of Health 2005) offers signifi- complexity of the disease process, the volume of cant opportunity for the development of integrated information that patients will need to assimilate, and the emotional burden of coming to terms with a chronic and progressive disease. It is common for

194 THE FOOT AND ANKLE IN RHEUMATOID ARTHRITIS primary/secondary models for providing foot health KEY POINTS services (see later section on Service Provision). ● The improvements in the medical management Disease staged management: late stage of RA require a review of models of foot health disease services provision. Regrettably, current experience suggests the effects on ● Foot health services provision needs to be the foot will usually become increasingly severe in responsive to the varying needs of the patient long-standing RA. The progressive structural changes throughout the course of the disease. that occurred initially as part of the inflammatory process enter into a vicious circle where mechanical ● There is a role for proactive management in early instability further exacerbates the rate of structural disease. change (Platto et al. 1991, Woodburn et al. 2002). In the late stage foot, subtalar and midtarsal joint subluxation SERVICE PROVISION leads to the well-described planovalgus foot posture and marked forefoot deformity. Severely deformed feet A growing number of bodies are recommending pro- may require orthopaedic referral, although many can vision of foot care as a minimum standard for patients be managed conservatively (Patsalis 1996). Good links with RA (ARMA 2004, Muir-Gray 1994, NWCEG 2002, with orthopaedics will smooth referral pathways and SIGN 2000). ensure the appropriateness of types and timing of referrals. Patients require information about surgical At present, the majority of foot health service options and careful counselling to ensure that they are provided to patients with RA is non-specialist and is able to make informed choices (ARMA 2004). Further provided predominantly by allied health profession- data are required on the timing and indication for sur- als (AHPs) and in the primary care environment gery in both the forefoot and rearfoot; surgical options (Department of Health 2003). Where more specialist are discussed in Chapter 7. rheumatology foot health is provided to people with RA, this usually occurs in the secondary or tertiary Service provision is still rooted in disease-specific sector, even if the services are contracted in from a management for most patients, but increasing multiple primary care based trust. Future provision of foot system involvement may require a shift toward a health services in rheumatology will be provided in a multiservice case-management approach: level 3 in the changed political climate, reflecting government pri- Long Term Conditions model (Department of Health orities. An overhaul of the management of long-term 2005). Mechanical management of the foot in late stage conditions is being launched at the time of writing, disease becomes more palliative in approach, and flex- further embedding chronic disease management in ible orthoses, often of the ‘total contact’ type are more the primary setting (Department of Health 2005). widely used in this group than in earlier disease Although the National Service Framework (NSF) for (Hodge et al. 1999). In-shoe orthotics may reduce plan- long-term conditions focuses on neurological dis- tar pain substantially, and advice on, or provision of ease, omitting rheumatology entirely (Department of more specialist footwear becomes more often necessary Health [in press]), the chronic disease management as disease duration increases (Fransen & Edmonds (CDM) and Long Term Conditions initiatives redress 1997, Williams & Bowden 2004). Management of the this omission to some degree. These two programs secondary features (corns, callus, nodules, bursae) provide for the appointment of community-based requires comprehensive podiatry input, with regular case coordinators such as community matrons, treatment the mainstays of footcare. This group of increasing the emphasis on multidisciplinary care patients may suffer from the diverse secondary features and on integrating specialists and generalists. of RA such as the vasculitis, ulceration and soft-tissue Integration across professional boundaries is written lesions noted in Chapter 3, and good footcare will into the policy, reinforcing the patient-centred require the input of a clinician with advanced skills and approach advocated by the professions themselves in expertise. During the later stages of disease, systemic the ARMA standards (ARMA 2004, Department of effects of RA become increasingly important, as cumu- Health 2004, 2005). lative damage to the hands and spine limits the patient’s ability to perform basic tasks of foot hygiene The NHS has been addressing some of these issues and self-care. The diverse nature of the needs of people as they relate specifically to AHPs through the develop- with late stage RA creates the greatest demand for care- ment of a working group and a self-assessment tool by fully managed skill mix. the National Primary and Care Trust Development Programme (NATPACT). The NATPACT programme

Organizing care 195 Points to consider: the NATPACT AHP relevant disciplines (for example orthotic services in Competency framework, assessing performance secondary care, podiatry in primary care) can work in eight areas against cross-boundary working. Some of the Department of Health guidelines for good chronic dis- ● Leadership – service leadership, AHP representation ease/long-term conditions management are outlined in decision making, developing AHPs. in below. ● Workforce – capacity and capability through Features of good chronic disease/long-term recruitment and retention of an appropriate mix of conditions management (Department of Health high-quality staff. Skill mix issues, service configu- 2004, 2005) ration, and acquisition of advanced skills. ● Stratifying patients by risk ● Corporate governance – aligning services with ● Involving patients in their care and promoting policy provision of formal criteria for service provision, managerial accountability. independence ● Treating patients sooner ● Clinical governance – provision of evidence-based ● Coordinating care services, professional and management accounta- ● Multidisciplinary team working bility, active involvement in research and audit, ● Integrating specialists and generalists appropriate training and information access. ● Integrating care across organizational boundaries ● Minimizing unnecessary visits ● Commissioning and service development – involve- ● Providing care in the least intensive setting and ment of AHPs in the commissioning process, recog- nition of training needs in Service Level nearer to home Agreements. While the basic foot health needs of many patients ● Performance management – AHPs actively involved in with RA can be addressed perfectly well by general- multi-agency and multidisciplinary initiatives, shared ists, the complexity of RA and the rapidity of change understanding of the outcome measures being used. in its medical management create a requirement for thorough and ongoing post-registration training. It is ● Access and choice – AHPs at the heart of challeng- essential that practitioners involved in the care of the ing traditional ways of working across the NHS, feet are kept up to date with developments in our AHP involvement in priority setting, AHP involve- understanding of the disease process and, more ment in intermediate care teams, AHP prescribing, crucially still, with the implications of modern drug single-assessment process, better care pathways, management. role development, better data collection, evidence for preventative work, proactive collaboration with In the secondary/tertiary setting it may possible to colleagues. provide a more specialized foot health service. One important aspect of more specialized foot care in a ● Partnership – lead AHPs contribute to planning rheumatology hospital department is the opportunity teams, AHPS are enabled to work across agency that is presented for multidisciplinary working. This is and organizational boundaries, AHP participation important in rheumatology as it becomes possible to in delivery of multi-agency, and interdisciplinary address two important limitations that were noted education, training and research. above. On the one side rheumatology patients are often complex medically, and multidisciplinary teams outlines a framework for assessing AHP-based services, allow the practitioner managing the foot problems to for use by PCTs, other commissioners and by the AHP communicate more effectively with, and receive back- service providers themselves (NATPACT 2003). up from the patient’s rheumatology physician. Conversely, with expertise in dealing with foot prob- NATPACT offers pointers and significant opportu- lems often limited among rheumatologists, closer con- nities for more strategic involvement of AHPs and the tact with foot specialists raises the profile of this services they provide in the chronic disease manage- neglected aspect of RA patient care in the mind of ment framework. medical specialists (Korda & Balint 2004). A foot health service for rheumatology patients The relevant foot health services can be readily should be able to deal with a spectrum of demand and mapped on to the ICF model. The main requirements are so should ideally provide services ranging from home treating impaired body structures and functions, helping assistance with basic foot care, through ongoing foot- care in the primary care setting, to specialist services such as foot orthoses, and management of high-risk foot in the secondary/tertiary setting and as part of a multidisciplinary team. The traditional home of the

196 THE FOOT AND ANKLE IN RHEUMATOID ARTHRITIS overcome existing impairment in body structures and 1994). There is good evidence that foot orthoses are function, limitations in activity and restrictions to partic- useful in controlling symptoms and in minimizing ipation, and preventing further impairment (Stucki et al. long-term change (Hodge et al. 1999, Kavlak et al. 2003, 2003): see Chapter 6. Woodburn 2000, Woodburn et al. 2002, 2003). In a Bradford multidisciplinary rheumatology clinic, some As such, foot health service provision can fall into 76% of patients required foot orthoses, and 43% five categories: replacement footwear (Helliwell 2003), while in a Rochdale audit, the requirement (note: not the provi- 1. Education and self-management advice, including sion) for orthoses and footwear was estimated to be footwear advice 60% and 51% respectively (Williams & Bowden 2004). Providing rheumatoid patients with off-the-shelf 2. Provision of, or assistance with finding orthoses orthopaedic footwear has been demonstrated to and footwear improve pain and function (Fransen & Edmonds 1997). 3. General foot care, nail cutting, corn and callus General foot care, nail cutting, corn and callus reduction, provision of padding reduction, provision of padding 4. High-risk management of the vasculitic or ulcera- Patients with musculoskeletal conditions have long tive foot been recognized as having an increased need for a range of basic foot care services (Muir-Gray 1994) with 5. Extended scope practice and surgery some three-quarters of rheumatology outpatients requiring routine foot care (Williams & Bowden 2004). These are summarized below but the interested Arthritis in the hands may make foot care and hygiene reader is directed to Chapter 6 for a more detailed tasks difficult (Mann & Horton 1996, Muir-Gray 1994), discussion. and hip and knee involvement can make bending to attend to basic foot-care tasks impossible. Education and self-management advice Management of the ‘high-risk’ vasculitic or In an era of increased patient empowerment education ulcerative foot programmes have become more commonplace. Self- management is known to result in improved health Management of the high risk foot accounts for approx- status (Rao & Hootman 2004), but there is conflicting imately one-quarter of the Leeds rheumatology foot evidence over the merit of formal education pro- health clinic’s appointments, and in one report of grammes for patients with rheumatic disorders. In the the case profile of multi-system wound care service, inflammatory diseases the measurable benefits are rheumatology patients made up 6% of the total case- related to short-term effects on drug compliance (Hill load (Steed et al. 1993). Prevention and management et al. 2001) and to psychological factors and impact of lesions in the high-risk foot is an important part of of disability (Riemsma et al. 2004). Education in RA the foot heath service in rheumatology (Korda & provides measurable improvement in knowledge, but Balint 2004) and some provision should be included in only small and non-significant changes in objective service planning. and health-related quality of life measures (Helliwell et al. 1999, Hill et al. 2001). Nevertheless, education is Extended scope practice and surgery important in allowing patients to participate in the management process and so provision of informa- The advent of the Extended Scope Practitioner (ESP) tion/education is considered a minimum standard in has created the opportunity for foot health services to the care of RA (ARMA 2004). Self-care/management is be more responsive to patients’ needs. The new ESPs a key pillar of the Long Term Conditions programme are able to access enhanced investigations and can and will receive increasing attention as this policy intervene more pro-actively, making amendments to matures. In order for self-care to work, education and patients’ pharmacological management and using information must be supplemented by a practical sup- injectable steroids (ARMA 2004). There are training port system (King’s Fund 2004). For general self-care issues to be considered that relate to the development relating to the foot, a comprehensive self management of ESPs, but there is great support for extending AHP package (the FOOTSTEP programme) has already roles, both from the professions themselves and from been described in Chapter 6. within rheumatology (Carr 2001). There is currently Orthoses and footwear Foot health departments should provide access to orthotic services for this patient group (Muir-Gray

Organizing care 197 no national accredited course so managers do not delivered outside of a multidisciplinary setting. Where have a de facto standard for ensuring competence, foot health services are available, the traditional model although groups such as the Academic and Clinical is that footcare is provided outside of the rheumatol- Unit of Musculoskeletal Nursing at Leeds run ‘M’ ogy department, usually by a podiatry, physiotherapy level modules aimed specifically at allied health pro- or orthotic department that may or may not even be fessionals working in rheumatology. The Society of located within the same trust. Such a situation does Chiropodists and Podiatrists (SCP) has an accredited not facilitate a ‘seamless’ service. core syllabus in rheumatology, and the SCP has worked with the Podiatry Rheumatic Care A superficial level of multidisciplinary care can be Association to accredit a demanding course, enabling provided by disciplines working independently, as suitably qualified AHPs to undertake injections of long as they have good lines of communication joints and soft tissues. Similar arrangements exist between them. This model of connected, but not inte- with the Chartered Society of Physiotherapists. In grated, care probably reflects the most common model 2005, the Arthritis Research Campaign funded the for what might be broadly considered multidiscipli- development of an ambitious postgraduate pro- nary foot health input into rheumatology. This model gramme, which offers a formal postgraduate qualifi- usually suffices because many rheumatology patients cation in rheumatology care to AHPs, and which are stable and well-managed medically, and compre- should provide an alternative option for accreditation hensive local foot health services can be provided of rheumatology specialist practice. The modular largely independently of rheumatology input. For a programme, accredited by the University of Brighton, significant minority of rheumatology patients, how- will be relevant to those working in an extended role ever, the complexity and severity of their disease in rheumatology and will operate primarily on a dis- means that better integration between their carers tance-learning basis, with some attendance at study would be of great benefit. days, and will be offered across the UK (see http//www.arc.org.uk). Within a rheumatology multidisciplinary team, rheumatology specialist nurses already play a central Training issues must be combined with local policy role (Redmond et al. 2005), responsible for adminis- initiatives such as the development of patient group tering, monitoring and modifying patients’ medica- directions (PGDs) for access to a range of prescription tion, education, and a valuable psychosocial support only medicines, and access arrangements for diagnos- role. In addition, the multidisciplinary team may tic services. The developing role of ESPs is potentially include any or all of a physiotherapist, occupational helpful to patients and exciting for the allied health therapist, podiatrist, orthopaedic surgeon, dietician, professions. orthotist, psychologist, pharmacist and social worker. The medical complexity of patients with RA, com- bined with the severity of deformity, require that the The therapy professions, specifically physiother- surgical care of these patients is usually undertaken in apy, podiatry and occupational therapy (OT) have an orthopaedic units. Surgical options are discussed in important role to play in the overall management of detail in Chapter 7. the symptoms and progression of inflammatory arthritis. The main roles for rehabilitation therapies WORKING IN A MULTIDISCIPLINARY are to help people limit disability through skills train- TEAM ing, exercise training, pain management, joint protec- tion programmes, and provision of splints and Multidisciplinary care is receiving a great deal of orthoses (Steultjens et al. 2004). The merit of providing attention at present in both rheumatology and in gen- splints as part of a regimen of OT has been demon- eral health policy (ARMA 2004, Department of Health strated, and echoes the data for foot orthoses provided 2004, 2005). The multidisciplinary model is attractive as part of podiatric management (Budiman-Mak et al. because it puts patients who have a very complex 1995, Steultjens et al. 2004, Woodburn et al. 2002). disease into contact with clinicians with equally spe- cific areas of expertise. Multidisciplinary foot care is What is the evidence base for multidisciplinary well established and of proven benefit in other disci- working? Prier et al. (1997) reported that the intro- plines such as diabetes (Edmonds et al. 1986), but pro- duction of a multidisciplinary clinic including nurse, vision of multidisciplinary foot health services in rheumatologist, physical therapist, social worker, rheumatology remains patchy. dietician, surgeon, psychologist and podiatrist was associated with increased patient satisfaction, We have already made the case that most of the foot improved knowledge and high demand for appoint- care provided to rheumatology patients appears to be ments, but not with measurable gains in quality of life. The experiences of the French are also outlined in two

198 THE FOOT AND ANKLE IN RHEUMATOID ARTHRITIS purely descriptive papers in which the desirability of Some generic governing principles for organizing a multidisciplinary service is outlined. No data to sup- a rheumatology foot health service port the efficacy of such an approach are provided in either paper, however (Claustre et al. 1979, Simon PRINCIPLE ONE et al. 1987). Patients with complex medical disease such as rheumatoid arthritis (RA) will benefit from a multi- A recent survey of rheumatology secondary/tertiary disciplinary approach to their foot care. care departments in the UK found that while 85% of rheumatology departments include rheumatology PRINCIPLE TWO specialist nurses in the team, and 44% include physio- Rheumatologists often do not understand enough therapy, only 27.1% include podiatry (Redmond et al. about the foot or about disciplines providing foot 2005). The provision of foot health services also varies care, while foot-care specialists such as podiatrists widely with geography, ranging from 65% in Yorkshire and orthotists often do not understand enough about and the North East; to 50% in London and the South the medical aspects of rheumatology. Education is East; to 25% and 33% in Scotland and Wales. Only half important, and communication of ideas is positive the rheumatology departments in our survey reported for all professions involved. having any access to foot heath services for important functions such as nail care and corn/callus reduction. PRINCIPLE THREE We have criticized the lack of coordination of foot A multidisciplinary rheumatology specific foot health services in rheumatology previously, noting the prob- service needs to be underpinned by the capacity to lems that are created with patient dissatisfaction, and provide a comprehensive general foot health service or impediment to the development of the service within the demands will outweigh the capacity for provision. the medical teams (Helliwell 2003). PRINCIPLE FOUR A MULTIDISCIPLINARY MODEL OF CARE Providing a multidisciplinary rheumatology foot health service carries skill-mix and training issues. The ARMA standards of care for RA call for agreed Some formal training and development is needed for pathways to be developed between rheumatology and specialist clinicians. Clinicians pursuing this type of the ancillary services (ARMA 2004) and this is recently specialist training provide strong role models for echoed in Department of Health Policy (Department other staff and can be excellent ambassadors for of Health 2005). allied health disciplines. Five basic principles are outlined in the text box PRINCIPLE FIVE opposite, but in the absence of any proven model we There is great goodwill between rheumatology and can offer no more than provide some pointers to assist foot health providers, which makes for a positive the reader in developing a service appropriate to their political climate in which to develop the multidisci- local circumstances. Some hints on developing a busi- plinary services. Commissioning of services is often ness plan are given later in the chapter. undertaken by a third party however. Goodwill is not a substitute for a strong business plan. The suggested model below is based on the follow- ing assumptions: Multidisciplinary rheumatology foot clinics in primary care ● Most foot care for rheumatology patients is cur- rently undertaken in primary care, or at least is Multidisciplinary care in the form of joint clinics is often provided by services based in primary care. impractical and may even be unnecessary, especially given the lower levels of medical demand in rheuma- ● The spectrum of disease severity is highly variable tology patients who are being successfully managed in in RA and so foot health services must cater for primary care. A more practical solution in this setting is patients with a wide range of foot problems. likely to come from initiatives designed to ensure better coordination between disciplines. At the service level, ● The service providing foot health has at least a will- issues to be considered include staff training and edu- ingness to train and develop individuals with spe- cation, the development of clear guidelines and path- cialist skills ways for referral, mechanisms to define prioritization ● Where truly multidisciplinary care is provided for patients with most complex rheumatoid disease, the ideal service setting moves from primary care to the rheumatology hospital department. ● Hospital-based multidisciplinary foot clinics in rheumatology are likely to revolve around the expertise of a few specialized individuals.

Organizing care 199 of resources, provision of timely and coordinated foot- vention improves prognosis and it is appropriate health services and evaluation of outcomes. for foot health services to offer a prioritized service to enable timely initiation of foot care for this Education and training is crucial in ensuring that patient group. staff involved in providing foot health services such as podiatrists, orthotists and physiotherapists understand (b) Established disease the medical context of the rheumatic diseases and are ● The foot is so often involved in the disease process familiar with the current standards of care in this rapidly changing field. Similarly, medical staff in rheumatoid arthritis (RA) that it is essential that involved in the care of rheumatology patients will usu- patients with RA receive regular foot health check ally benefit from improved education about the foot in ups. It is recommended that foot health is assessed health and in the rheumatic diseases. It is our experi- at least annually (by medical/nursing staff or by a ence that in addition to the obvious educational gains, podiatrist or other AHP), and that patients are both sides benefit greatly from the improved profes- given adequate recourse to services should prob- sional understanding that goes with cross-discipline lems arise. Again, it is appropriate for foot health education and training. services to offer a prioritized service to enable timely initiation of foot care should the need arise. In the absence of a nationally agreed pathway or guidelines for referral, formal local arrangements are ● Structural changes in the foot will usually worsen an absolute necessity. As noted above, only 6% of with increasing disease duration, and the benefit of rheumatologists knew of any guidelines for referral to early mechanical intervention in this patient group foot health services local to them. In the absence of for- is now well documented. Secondary lesions mal policy, access to foot health services for rheuma- (callus/bursae/nodules) are more common in tology patients will continue to be unnecessarily established disease and indirect problems, such as patchy, and provision of foot health services will be, at difficulty with basic foot care or nail cutting, arising best, disjointed and, at worst, nonexistent. from the systemic effects of disease may manifest. While referral to a specialist rheumatology foot The North West Region’s Clinical Effectiveness health service may be ideal, all of these manifesta- Group for the Foot and Ankle in the Rheumatic dis- tions can usually be managed satisfactorily by a eases offers some useful pointers for local planning suitably trained generalist within a primary care and we have combined their recommendations and clinical setting. our own experiences into the referral/care pathway model seen below. ● In a small proportion of patients, however, the severity of the disease process, complexity of sec- Suggested referral guidelines ondary features, or the effects of medical therapy may give rise to more sophisticated needs (see (a) Early disease ‘high risk features in Table 9.1). Where possible, ● At the time of diagnosis of inflammatory disease, these needs should be addressed by foot health services well integrated with the rheumatology any foot manifestations should be assessed in all team and provided by practitioners with specialist patients (by medical/nursing staff or by a podia- skills in managing the foot in RA (with acknowl- trist or other AHP). edgement to the UK North West Region’s Clinical Effectiveness Group). ● In the absence of foot problems, basic foot-health advice should be given by medical/nursing/AHP Table 9.1 outlines how needs in early RA may be staff to provide signposting for future needs, as mapped onto foot health services that should be pro- well as to gently encourage positive foot health and vided to these patients. footwear habits in the vulnerable patient. Early foot-health education should be mindful of infor- The definition of formal agreements has obvious mation overload. Written reinforcement should be benefits in prioritizing resources, and in underpinning provided to ensure that patients have material to the business case for additional resources where refer to if problems arise subsequently. appropriate. A wide variation in figures for foot health service provision to rheumatology patients has the ● There is inadequate evidence at present for the potential to provide a useful lever for areas where pro- efficacy of any preventative measures, and, in viding such services has been difficult in the past. the absence of any foot pathology, no referral into Setting out a formal plan can also be helpful in high- foot health services would be necessary at this lighting gaps between need and provision. stage. If foot problems exist, however, then imme- diate referral to foot health services is appropriate. In patients with inflammatory arthritis, early inter-

200 THE FOOT AND ANKLE IN RHEUMATOID ARTHRITIS Provision of foot care to rheumatology patients in It would also be quite appropriate to extend team the primary sector will have to reflect the diverse membership to orthopaedics, physiotherapy and needs of this group of people, ranging from footwear occupational therapy as resources permit. The accom- and self-care advice, through basic foot care, manage- modation requirements for a joint clinic are also sig- ment of soft tissue problems, provision of padding nificant. A rheumatology foot clinic requires a fairly and orthoses, and ongoing care of ulceration and other large room, with at least a 5 m unobstructed area to ‘high-risk’ foot presentations. Most recent policy on allow for observation of gait, one or more examina- managing chronic disease suggests that case-mix pro- tion couches, and/or a podiatry/chiropody work- filing to stratify patients according to need or risk is an station. Facilities for plaster casting are a minimum important first step in implementing effective CDM and a raised platform is helpful. It is possible for these (Department of Health 2005, King’s-Fund 2004). There facilities to be provided on a temporary basis so that is considerable scope for a heavily skill-mix-orien- the room can also be used by other disciplines, but a tated approach here, employing care assistants, regis- dedicated room is preferable. tered generalists, and for more complex patient specialists and ESPs/AHP consultants as appropriate. Once the service is established, some succession The provision of a multidisciplinary/interdisciplinary planning is imperative, as small teams such as these service in primary care can be driven by a single serv- can be highly dependent on individual personalities ice (such as podiatry) and so, to some degree, can be enabled by review of existing working practices. Points to consider in developing a business case for a multidisciplinary foot clinic Multidisciplinary rheumatology foot clinics in secondary/tertiary care 1. Establish a need for the service: a. Use epidemiological data on foot problems Provision of rheumatology foot health services in sec- related to the local population and different ondary care more usually occurs in the context of the age groups rheumatology ward or outpatients department. In this b. Use epidemiological data on high-risk groups context it is often easier, at least from the logistic per- c. Provide existing data on use of services in both spective, to provide a truly multidisciplinary approach primary and secondary care as the centralized hospital location and the likely case profile of rheumatology department patients lends 2. Identify existing resources: itself better to interdisciplinary working and joint clin- a. Rheumatology and orthopaedic clinics ics. It must be acknowledged, however, that a joint b. Orthotic services clinic approach is only targeting the top end of the serv- c. Podiatry services ice pyramid, emphasizing levels two and three. Some mechanism should also exist to enable a hospital-based 3. Identify existing costs: rheumatology foot clinic to articulate with foot services a. What is the orthotic budget? in primary care so that the wider spectrum of patient b. What are the podiatry costs for the existing needs can be met. client group c. What are indirect costs – if the patient has to In contrast to the model of adapting an existing make three separate journeys, for example primary care service outlined in the previous section, establishing a secondary care rheumatology foot 4. Identify purchasers and providers – you will need health clinic requires the direct input of both the to make the case for a combined foot clinic to the rheumatology department and the relevant AHP dis- major purchaser – the primary care trust ciplines. It is our experience that there is usually con- siderable goodwill between all parties, but that a 5. Identify benefits: significant limiting factor will be the availability of No cost implications with improved quality of care financial resources. There can be large discrepancies between the desire to provide a service and the capac- 6. Develop business case within this framework ity to pay for it. Some of the essentials of a good General points to note: business plan are given in the text box below ● Consider the principles outlined under ‘Features (adapted from Marshall 2004). of good chronic disease/long-term conditions management’ in this chapter. The staff mix of a multidisciplinary foot team in ● Although the combined multidisciplinary foot a hospital rheumatology department should include clinic will provide a better quality of care argu- at least a rheumatologist, podiatrist and an orthotist. ing this is unlikely to have much impact in a cost limited service. Therefore, the case has to be made by organizing existing services more effectively: this is the basis for the business Continued on page 202

Table 9.1 Indicators for foot health referral and appropriate associated services in early and established RA. Indicators for referral for foot health intervention Services Localized joints/soft Problems affecting the Secondary lesions ‘High-risk’ features potentially tissue inflammation architecture or function (callus/corns/nodules/bursae) appropriate to of the foot Not usually applicable in presenting features Foot health advice Foot health advice early RA in early RA. Footwear advice Foot health advice Provision of information re Local splinting Footwear advice Baseline can be established if Services potentially Physical therapies Provision of foot wear pathological processes occurring patient attending for other reasons appropriate to Provisions of information re Cautious reduction of skin lesions if presenting features (rest/ice) Evaluation of vascular/neurological in established RA Padding pathological processes appropriate status – establishment of baselines Functional intervention occurring Self management advice if the Functional foot orthoses Integrated care with rheumatology (functional foot Periodic review and patient is able enough team orthoses) monitoring of structural Footwear advice Joint or soft tissue change (at least annually) Capacity to undertake more complex injections Provision of footwear if appropriate wound care Periodic review as as above plus Padding/pressure relief appropriate Provision of functional Functional intervention (functional Management self-referral mechanism as above foot orthoses (softer foot orthoses materials) Periodic review (at least annually) Provision of customized footwear as above plus Palliation of local lesions Injection of soft tissue lesions secondary to structural Minimal reduction of callus overlying change Consideration for surgical plantar bursae intervention Monitoring for ulceration Organizing care 201

202 THE FOOT AND ANKLE IN RHEUMATOID ARTHRITIS Points to consider in developing a business case (Helliwell 2003, Prier et al. 1997). Robust business for a multidisciplinary foot clinic—cont’d planning should pre-empt these potential problems and aid the long-term success of such a venture. As we case. An example would be to establish the have noted in the previous chapter, supplementing the annual budget for bespoke footwear and use a initial business plan with careful documentation of reduction in that (due to better selection of patient outcomes will enable the merits of the service patients and use of alternative treatments) as to be quantified and the cost-effectiveness evaluated one way to fund the improved service. Another in the long term (Prier et al. 1997). would be to introduce a self-management pro- gramme for the many elderly people attending KEY POINTS for routine podiatry care and to use the savings on the new multidisciplinary clinic. ● Multidisciplinary care should be patient facing, ● Use National targets in your case. Examples are i.e. should relate to meeting patient needs rather the ARMA standards of care and the NSF for than reinforcing professional scopes of practice. long-term conditions. ● Use other benefits such as retention of high- ● Most services are currently provided in the quality staff. primary care setting. ● It may be possible to use waiting times as a lever to introduce this service ● The members of the multidisciplinary team need ● In the business plan you will need to identify not be physically present at the same time. the costs of the project (both capital and running) and match these against the savings ● There is a need for common currency among identified above. team members (e.g. assessment protocols, care ● Work together with colleagues. It is possible pathways, standards of care). orthopaedic colleagues would welcome the chance to provide a quality based conservative ● Multidisciplinary and resourcing issues should be option considered from the outset. ● Look to other specialties. It is likely that the diabetes service is running such a clinic and it SUMMARY may be possible to graft your new service onto theirs at little extra cost. There is currently a large gap between need and provi- sion of foot health services to rheumatology patients, for their success. To ensure a level of professional generally, and wide geographical variation in what development appropriate to a specialist team it is services do exist. The needs of this group of patients advisable that arrangements are made for continuing are extremely diverse and require services at a variety professional development, and for update courses for of levels. Government and professional policy is the foot health specialist to be undertaken jointly with increasingly supportive of the role of AHPs in provid- the rest of the rheumatology team (Otter 2004). ing such care, however, and the combination of diverse needs and developing policy offers exciting opportuni- A good multidisciplinary rheumatology foot health ties for developing foot health services. There is great service is likely to tap into considerable unmet need scope in the model outlined in this chapter to develop for foot health services (Prier et al. 1997) and it is our foot health services while building a career structure and others’ experience that the service will expand and developing specialist AHPs. Resource implications rapidly and attract referrals for a range of conditions should be addressed by a robust business plan at the outset of any new initiatives. References ARMA Standards of Care for People with Inflammatory Arthritis. Arthritis and Musculoskeletal Alliance, Akesson K, Dreinhofer KE and Woolf AD Improved London, 2004. education in musculoskeletal conditions is necessary for all doctors. Bulletin of the World Health Organization Backman CL, Kennedy SM, Chalmers A and Singer J 2003; 81(9): 677–683. Participation in paid and unpaid work by adults with

Organizing care 203 rheumatoid arthritis. Journal of Rheumatology 2004; Gorter K, de Poel S, de Melker R and Kuyvenhoven M 31(1): 47–56. Variation in diagnosis and management of common Badley EM The provision of rheumatologic services. In: foot problems by GPs. Family Practice 2001; 18(6): Klippel J, Dieppe P (eds) Rheumatology, Mosby, London, 569–573. 1994. Breedveld FC, Emery P, Keystone E et al. Infliximab in GorterKJ, Kuyvenhoven MM and de Melker RA active early rheumatoid arthritis. Annals of the Nontraumatic foot complaints in older people. A Rheumatic Diseases 2004; 63(2): 149–155. population-based survey of risk factors, mobility, and Budiman-Mak E, Conrad KJ, Roach KE et al. Can foot well-being. Journal of the American Podiatric Medical orthoses prevent hallux valgus deformity in rheumatoid Association 2000; 90(8): 397–402. arthritis? A randomized clinical trial. JCR: Journal of Clinical Rheumatology 1995; 1(6): 313–121. Harvey I, Frankel S, Marks R, Shalom D and Morgan M Carr A Defining the extended clinical role for allied health Foot morbidity and exposure to chiropody: population professionals in rheumatology. Arthritis Research based study. British Medical Journal 1997; 315(7115): Campaign 2001; proceeedings No 12. 1054–1055. Cawley MI Vasculitis and ulceration in rheumatic diseases of the foot. Baillie`res Clinical Rheumatology 1987; 1(2): HEFCE Higher Education Funding Council for England 315–333. report on research in nursing and allied health Claustre J, Simon L and Serre H [Rheumatoid foot. Practical professions. Department of Health/HEFCE, London, podiatric problems]. Revue du Rhumatisme et des 2001. Maladies Osteo-Articulaires 1979; 46(12): 673–678. Crawford F and Thomson C Interventions for treating Helliwell PS Lessons to be learned: review of a plantar heel pain. [update of Cochrane Database Syst multidisciplinary foot clinic in rheumatology, Rev. 2000;(3): CD000416; PMID: 10908473], Cochrane Rheumatology 2003; 42(11): 1426–1427. Database of Systematic Reviews 2003; 3, p. CD000416. Davys H, Turner D, Helliwel PS,Emery P and Woodburn J Helliwell PS and OHara M Shared care between hospital A comparison of scalpel debridement versus sham and general practice: an audit of disease-modifying procedure for painful forefoot callosities in rheumatoid drug monitoring in rheumatoid arthritis. British Journal arthritis. Rheumatology Diseases 2005; 44: 207–210. of Rheumatology 1995; 34(7): 673–676. Department-of-Health NHS Chiropody Services Summary Information for 2002–03, England, DH Statistics Division Helliwell PS, OHara M, Holdsworth J, Hesselden A, King T (SD3G), 2003. and Evans P A 12-month randomized controlled trial of Department-of-Health Improving Chronic Disease patient education on radiographic changes and quality of Management, London, 2004. life in early rheumatoid arthritis. Rheumatology 1999; Department-of-Health Supporting People with Long Term 38(4): 303–308. Conditions, London, 2005. Department-of-Health National Service Framework for Hewlett S, Mitchell K, Haynes J, Paine T, Korendowych E Long Term Conditions, London (in press). and Kirwan JR Patient-initiated hospital follow-up for Devauchelle-Pensec V, Saraux A, Alapetite S, Colin D and rheumatoid arthritis. Rheumatology 2000; 39(9): Le Goff P Diagnostic value of radiographs of the hands 990–997. and feet in early rheumatoid arthritis. Joint Bone Spine 2002; 69(5): 434–441. Hill J An overview of education for patients with rheumatic Edmonds ME, Blundell MP, Morris ME, Thomas EM, Cotton diseases. Nursing Times 2003; 99(19): 26–27. LT and Watkins PJ Improved survival of the diabetic foot: the role of a specialized foot clinic. Quarterly Hill J, Bird H and Johnson S Effect of patient education on Journal of Medicine 1986; 60(232): 763–771. adherence to drug treatment for rheumatoid arthritis: a Emery P and Seto Y Role of biologics in early arthritis. randomised controlled trial. Annals of the Rheumatic Clinical and Experimental Rheumatology 2003; Diseases 2001; 60(9): 869–875. 21(5 Suppl. 31): S191–S4. Fransen M and Edmonds J Off-the-shelf orthopedic Hodge MC, Bach TM and Carter GM Novel Award First footwear for people with rheumatoid arthritis. Arthritis Prize Paper. Orthotic management of plantar pressure Care and Research 1997; 10(4): 250–256. and pain in rheumatoid arthritis. Clinical Biomechanics Garrow AP, Silman AJ and Macfarlane GJ The Cheshire Foot 1999; 14(8): 567–575. Pain and Disability Survey: a population survey assessing prevalence and associations. Pain 2004; 110(1–2): 378–384. Kavlak Y, Uygur F, Korkmaz C and Bek N Outcome of Gorter K, Kuyvenhoven M and de Melker R Health care orthoses intervention in the rheumatoid foot. Foot and utilisation by older people with non-traumatic foot Ankle International 2003; 24(6): 494–499. complaints. What makes the difference? Scandinavian Journal of Primary Health Care 2001; 19(3): 191–193. Kings-Fund Managing Chronic Disease: what can we learn from the US experience? Kings Fund, London, 2004. Korda J and Balint GP When to consult the podiatrist. Best Practice and Research in Clinical Rheumatology 2004; 18(4): 587–611. Mann RA and Horton GA Management of the foot and ankle in rheumatoid arthritis. Rheumatic Diseases Clinics of North America 1996; 22(3): 457–476. Memel DS and Kirwan JR General practitioners knowledge of functional and social factors in patients with rheumatoid arthritis. Health and Social Care in the Community 1999; 7(6): 387–393.

204 THE FOOT AND ANKLE IN RHEUMATOID ARTHRITIS Michelson J, Easley M, Wigley FM and Hellmann D Foot Steed DL, Edington H, Moosa HH and Webster MW and ankle problems in rheumatoid arthritis. Foot and Organization and development of a university Ankle International 1994; 15(11): 608–613. multidisciplinary wound care clinic. Surgery 1993; 114(4): 775–778, discussion 8–9. Muir-Gray J Feet first: Report of the joint department of health and NHS chiropody taskforce, Department of Steultjens EMJ, Dekker J, Bouter LM, van Schaardenburg D, Health, London, 1994. van Kuyk MAH and van den Ende CHM Occupational therapy for rheumatoid arthritis. Cochrane Database of Munro BJ and Steele JR Foot-care awareness. A survey of Systematic Reviews 2004; 2: 2. persons aged 65 years and older. Journal of the American Podiatric Medical Association 1998; 88(5): 242–248. Stucki G, Ewert T and Cieza A Value and application of the ICF in rehabilitation medicine. Disability and NATPACT AHP Significant Issues Group NHS. Rehabilitation 2003; 25(11–12): 628–634. Modernisation Agency, London, 2003. Vliet Vlieland TP and Hazes JM Efficacy of NWCEG North West Clinical Effectiveness Group. multidisciplinary team care programs in rheumatoid Guideines for the management of the foot in rheumatic arthritis. Seminars in Arthritis and Rheumatism 1997; diseases, 2002. 27(2): 110–122. Otter SY, and Cryer J Biologic agents used to treat Wagner EH The role of patient care teams in chronic disease rheumatoid arthritis and their relevance to podiatrists: management. British Medical Bulletin 2000; 320(7234): a practice update. Musculoskeletal Care 2004; 2(1): 51–59. 569–572. Patsalis T, Georgousis H and Gopfert S Long-term results of Waxman R, Woodburn H, Powell M, Woodburn J, forefoot arthroplasty in patients with rheumatoid Blackburn S and Helliwell P FOOTSTEP: a randomized arthritis. Orthopedics 1996; 19(5): 439–447. controlled trial investigating the clinical and cost effectiveness of a patient self-management program for Platto MJ, OConnell PG, Hicks JE and Gerber LH The basic foot care in the elderly. Journal of Clinical relationship of pain and deformity of the rheumatoid Epidemiology 2003; 56(11): 1092–1099. foot to gait and an index of functional ambulation. Journal of Rheumatology. 1991; 18(1): 38–43. White EG and Mulley GP Footcare for very elderly people: a community survey. Age and Ageing 1989; 18(4): 276–278. Prier A, Berenbaum F, Karneff A et al. Multidisciplinary day hospital treatment of rheumatoid arthritis patients. Williams AE and Bowden AP Meeting the challenge for foot Evaluation after two years. Revue du Rhumatisme health in rheumatic diseases. Foot 2004; 14(3): 154–158. (English Edition) 1997; 64(7–9): 443–450. Woodburn J, Stableford Z and Helliwell PS Preliminary Rao JK and Hootman JM Prevention research and rheumatic investigation of debridement of plantar callosities in disease. Current Opinion in Rheumatology 2004; 16(2): rheumatoid arthritis. Rheumatology 2000; 39(6): 652–654. 119–124. Woodburn J, Barker S and Helliwell PS A randomized Redmond A, Allen N and Vernon W Effect of scalpel controlled trial of foot orthoses in rheumatoid arthritis. debridement on the pain associated with plantar Journal of Rheumatology 2002; 29(7): 1377–1383. hyperkeratosis. Journal of the American Podiatric Medical Association 1999; 89(10): 515–519. Woodburn J, Helliwell PS and Barker S Changes in 3D joint kinematics support the continuous use of orthoses in the Redmond AC, Helliwell PS, Waxman R Provision management of painful rearfoot deformity in of foot health servicess in rheumatology in rheumatoid arthritis. Journal of Rheumatology 2003; the UK. Rhematology (adance access on-line 2005). 30(11): 2356–64. Riemsma RP, Kirwan JR, Taal E and Rasker JJ Patient Woodburn J, Udupa JK, Hirsch BE et al. The geometric education for adults with rheumatoid arthritis. Cochrane architecture of the subtalar and midtarsal joints in Database of Systematic Reviews 2004; 2: 2. rheumatoid arthritis based on magnetic resonance imaging. Arthritis and Rheumatism 2002; 46(12): Salvage A Feet last? Older people and NHS chiropody 3168–3177. services. Podiatry Now 1999; 1: 7–11. Young A, Dixey J, Cox N How does functional disability in SIGN Scottish Intercollegiate Guidelines Network. early rheumatoid arthritis (RA) affect patients and their Management of Early Rheumatoid Arthritis, 2000. lives? Results of 5 years of follow-up in 732 patients from the Early RA Study (ERAS). Rheumatology 2000; 39(6): Simon L, Brun M, Izard MH and Houlez G [Teaching the 603–611. patients with rheumatoid polyarthritis more about their disease]. Revue du Rhumatisme et des Maladies Osteo- Articulaires 1987; 54(5): 393–395.

205 Index Please note that page references to non-textual information such as Figures and Tables are in italic print A ankle Betts, RP, 50–51 and gait analysis, 26, 31, 37 biological drugs, 118–119, 120, ABPI (Ankle Brachial Pressure Index), 94 medial, 31 Achilles bursitis, 11, 65, 109–110, 126 sagittal plane feature, 26, 39 121 Achilles tendinopathy, 108–109 sub-talar joints, 108 Birke, JA, 95 Achilles tendon surgical management, 165–167 bisphosphonates, 119 synovial swelling at, 88 bleeding, and intra-articular therapy, clinical assessment, 88 see also foot and ankle nodules on, 128 123 and retrocalcaneal bursa, 126 Ankle Brachial Pressure Index (ABPI), 94 blood, and hyperviscosity syndrome, 71 rheumatoid nodules in, 70 Ankle-Hindfoot (AH), scoring system, 83 body weight, and synovial inflammation, weakness of, 109 ankylosing spondylitis, 115 ACR (American College of Rheumatology), anti-malarial drugs, 116, 117 57 anti-nuclear factor, 119 bone-marrow oedema, 100 2, 9, 150, 172, 174, 184 AOFAS (American Orthopedic Foot and Bouysset, M, 11 ACR-20 scores, 118 British Footwear Association, 148 acute phase markers, 77, 79, 173, 183 Ankle Society),182 British Society for Rheumatology, adalimumab, 118 ARMA (Arthritis and Musculoskeletal ADL (activities of daily living), and 120 Alliance), 114, 192, 198 bupivicaine, 128 functional status, 176 artefacts, in ultrasound, 104 buprenorphine patches, 114 adventitious bursae, 65, 126 Arthritis Measurement and Impact Scale Burns, SL, 84 age bursae (AIMS), 180 impairment, affecting, 62 Arthritis and Musculoskeletal Alliance adventitious, 65, 126 as risk factor, 4 and clinical features of foot, 65 AH (Ankle-Hindfoot), scoring system, 83 (ARMA), 114, 192, 198 definition, 105 AHPs (allied health professionals), 194, 196, Arthritis Research Campaign, 135, 197 detection, 105 arthroplasty procedures, and plantar injection of, 126 202 location, 65 AIMS (Arthritis Measurement and Impact pressure distribution, 50 retrocalcaneal, 11, 65, 109–110, 126 atherosclerosis, risk factors, 68 synovitis within, 108 Scale), 180 atrophy, intra-articular therapy, 123 bursitis Aircast Pneumatic Walkers, 154 attenuation, 12, 58 Achilles, 11, 65, 109–110, 126 algorithms, gait analysis, 20, 41 auranofin, 117 rice body, 105 Alkaabi, JK, 68 avascular necrosis, 106 allied health professionals (AHPs), 194, 196, C B 202 C-reactive protein (CRP), 77, 79, 173 ambulation, synovial inflammation, 57 Baylan, SP, 69 calcaneal enthesopathy, 64–65 American College of Rheumatology (ACR), beam edge artefacts, and ultrasound, 104 calcaneal spurs, 11, 65 Benjamin, M, 64 calcaneocuboid joints, 107–108 2, 9, 150, 172, 174, 184 ‘Berg balance’ test, 177 calcaneonavicular ligament, 31, 32 American Orthopedic Foot and Ankle Berthelot, JM, 3 Society (AOFAS), 182 anakinra (anti-IL1), 119 analgesia, 114, 128,129 anisotropy, and ultrasound, 104

206 INDEX calluses Clinical Effectiveness Group for the Foot diet, as risk factor, 4 under metatarsal heads, 60 and Ankle in the Rheumatic diseases dihydrocodeine, 114 problematic when, 65 (North West Region), 199 Disease Activity Score (DAS), 61–62, 79, reduction, 151, 152 see also corns and calluses clinical features (foot), 57–74 173, 184 bursae, 65 DAS28 modification, 183, 184 capacity qualifiers, impairment, 8 corns and calluses, 65 as gold standard, 183 care disease activity, 61–62 disease staged management enthesopathy, 64–65 early disease, 9–10, 192–193 evaluating, 169–188 extrinsic factors, 62–63 foot health and medical services, 189–192 functional status, 63–64 classification criteria, 3 models of, 192–194 intrinsic factors, 61–62 foot clinics, 199 lifestyle demands, 62–63 HAQ, 62 multi disciplinary, 198–202 modifying factors/associated symptoms, joint symptoms, 59–60 organizing, 189–204 61–63 othoses, 138–139 service provision see service provision nail abnormalities, 65 established disease, 10–13, 193–194 carpal tunnel syndrome, and compression psycho-social factors, 62–63 forefoot, 12–13, 106–107 social-cultural factors, 63 joint symptoms, 59–60 neuropathy, 68, 69 midfoot, 11–12, 107–108 casting techniques, foot orthoses, 142 clinics, rheumatology see rheumatology foot orthoses, 140 CDM (Chronic Disease Management), 190, clinics, multidisciplinary rearfoot, 10–11, 107–108 late stage disease, 194 191, 192, 200 Cochrane Systematic review, patient distal sensory neuropathy, 69–70 centre of pressure (COP), and gait analysis, education, 133 Dixon, AJ, 59 Dixon, St.J, 121, 126 35, 37, 38, 40, 46, 47 codeine, 114 DMARDs (disease-modifying anti- Chamberlain, MA, 69 combination drug regimes, 119–120 Chantlau, E, 148 compensation strategies, 47, 58 rheumatic drugs) Chartered Society of Physiotherapists, 197 compression neuropathies, 68–69 biological drugs, 118–119 chisel toe, 13 computerized tomography (CT), 164, 173 case studies, 146 chloroquine phosphate, 117 concurrent validity, and validation clinical responses, factors influencing, 120 Chronic Disease Management (CDM), 190, improvements in therapy, 120 processes, 175 multiple, 114 191, 192, 200 COP (centre of pressure), and gait analysis, new onset RA, optimal approach, 120 classification criteria, rheumatoid arthritis, traditional, 116–117, 120–121 35, 37, 38, 40, 46, 47 see also drug management 2 corns and calluses Doppler ultrasound, 3, 94, 102 clinical assessment drug management, 5, 100, 113–121 and clinical features of foot, 65 analgesics, 114 disease activity in foot, 78–82 reduction, 151, 196 biological drugs, 118–119, 120, 121 feel, 88–90 corticosteroids, 120, 121, 122 case study, 23 costs of RA, 5–6 clinical response to disease modifying forefoot, 90 ‘court’ shoes, 59 midfoot, 90 COX-1 and COX-2 specific NSAIDs, 115, drugs, 120 rearfoot, 88–89 combination regimes, 119–120 foot posture, 84 116 corticosteroids, 120, 121, 122 footwear, 84 CRP (C-reactive protein), 77, 79,173 DMARDS see DMARDs (disease- joint counts, 174 CT (computerized tomography), 164, 173 look, 83–88 cyclosporine, 117 modifying anti-rheumatic drugs) foot posture, 84 cysts, detection, 105 evaluation, 120–121 footwear, 84, 88 cytokines, 6, 7 historical aspects, 113–114 joint deformity, 83–84 hypersensitivity reactions, 119 muscle, 84 D intra-articular therapy, 121–130 skin, 84 newer treatments, 117–118 methods, 9 D-penicillamine, 117 non-steroidal anti-inflammatory drugs, muscles see muscle disease; muscle DAS (Disease Activity Score), 61–62, 79, 173 52, 113, 114–116 testing; muscles DAS28 modification, 183, 184 step down approach, 114, 115, 119–120 neurological assessment, 95–96 as gold standard, 183 steroid treatment see steroids pain, 77–78, 79 de Jong, Z, 150 traditional drugs, 116–117 principles, 82–94 deformity see also side effects proforma, tenderness and swelling, 80 clinical assessment, 83–84 progression of disease, monitoring, pes planovalgus see pes planovalgus E 77–78 deformity early disease, 9–10, 192–193 proprioception, 96 rearfoot, 13 classification criteria, 3 reflexes, 96 toe, 43 foot orthoses, 136, 138–139 screening tools, 75–77 varus, 58, 164 HAQ, 62 skin, 84 Dereymaeker, G, 51 joint symptoms, 59–60 stiffness, 82 DH Pressure Relief Walkers, 154 referral guidelines, foot clinics, 199 swelling, 79 diabetes mellitus, 95–96 Diabetic Patient Education Programmes, recording of counts, 80 suggested count, 81 134 temperature, 96 diclofenac, 114 tenderness, 79, 82 recording of counts, 80 suggested counts, 81 vascular system, 94–95

INDEX 207 EBV (Epstein-Barr virus), 6 exercise, benefits of, 150, 151 foot and ankle (Continued) Edmonds, J, 20 Expert Patients Programme, 134–135 nerve blocks, 128–130 electric footswitch systems, gait analysis, 20 Extended Scope Practitioner (ESP), rheumatoid joint, general features, 106 electromyography (EMG), 11 see also foot 191, 196 and muscle function, 51 extra-articular disease, 65–71, 104–106 foot care, inability to maintain own, 62 EMG (electromyography) see foot disease bursae, 105 electromyography (EMG) cysts, 105 assessment of activity, 78–82, 169–170 Empire Rheumatism Council, 116 ganglia, 105 early see early disease employment issues, and RA, 5, 63 hyperviscosity syndrome, 71 epidemiology of, 9–13 energy consumption, gait analysis, 52 leg ulceration, 67 established see established disease Eng, JJ, 39–40 macrovascular, 67–68 extra-articular see extra-articular enthesis, defined, 64 masses, peri-articular, 105 enthesopathy, and clinical features of foot, muscle disease, 71 disease neuropathy, 68–70 forefoot, 12–13 64–65 sub-cutaneous nodules, 70 historical aspects, 10 entrapment syndromes, and neuropathies, tendon and ligament pathology, intra-articular, 100–104, 101, 102 late stage, 194 69 104–105 midfoot, 11–12 epidemiology 2–3, 9–13 vasculitis, 66, 67 Epstein-Barr virus (EBV), 6 imaging techniques, 107–108 EQ-5D (EuroQol Group), 178, 179–180 F nail abnormalities, 65 erosions prevalence, 13–14 face/content validity, and validation progression of, 13–14 detection (intra-articular disease), 100, processes, 175 101, 102 evaluating, 172–184 fentanyl, 114 monitoring, 77–78 metacarpophalangeal joints, 12 FFI (Foot Function Index), 181, 183 RA, 2–3 metatarsal joint disease, 106–107 FHSQ (Foot Health Status Questionnaire), rearfoot, 10–11 ESP (Extended Scope Practitioner), 191, 196 imaging techniques, 107–108 ESR (Erythrocyte Sedimentation Rate), 182 soft tissues, 108–110 fibular styloid, nerve block at, 129–130 see also evaluation of disease progress; acute phase markers, 77, 79 50-foot walking time, gait analysis, 20 established disease, 10–13, Figgie, MP, 165 joint disease flat feet, 11 Foot Function Index (FFI), 181, 183 193–194 Fleming, A, 9 foot health and medical services, foot orthoses, 140 flurbiprofen, 114 forefoot, 12–13, 106–107 foot 189–192 intra-articular injections, 123 Foot Health Status Questionnaire (FHSQ), joint symptoms, 59–60 care of see foot care midfoot, 11–12, 107–108 clinical features see clinical features (foot) 182 rearfoot, 10–11, 107–108 deformities of, 43, 59 foot posture, 84 referral guidelines, foot clinics, 199–200 footprint, walking, 41 spontaneous remission, 4 hindfoot, 58 FOOTSTEP self-management programme etanercept, 118 rearfoot, 13 EULAR handbook, 82 see also pes planovalgus deformity (SMP), 134, 135, 196 EuroQol Group (EQ-5D), 178, 179–180 disease of see foot disease footwear evaluation of disease progress, 172–184 examination of, 82 acute-phase markers, 173 forefoot see forefoot assessment, 84, 88 ‘Berg balance’ test, 177 functional status see functional status ‘court’ shoes, 59 EuroQol Group (EQ-5D), 178, 179–180 high-risk, 152–155 and Leeds Foot Impact Scale, 8 functional status see functional status service provision, 196 orthopaedic, off-the-shelf, 63 health status joint loading in, 57 podiatry management, 146, 148–150 see also forefoot: loading of service provision, 196 composite measures, 183–184 midfoot see midfoot trainers, 60 concept, 170 orthoses of see ortheses, foot see also orthoses, foot disease-specific measures, 180–181 painful toes, 9 forefoot generic measures, 179 planovagus, in RA, 47–48 abducted, 41 region specific measures, 181–183 rearfoot, 13 assessment, 90 imaging of change, 173–174 rearfoot see rearfoot disease of, 106–107 joint counts, 174 ulceration, 153, 154, 162 established disease, review, 12–13 laboratory markers, 173 see also foot and ankle impairments, documentation of, 24 Medical Outcomes Survey (SF-36), 178, foot and ankle loading of, 44, 45, 46, 48 extra-articular disease, 104–106 179 imaging, 99–112 and toe deformity, 43 objective measures, 172–178 importance of, 99–100 pain in, 106 rheumatoid factor, 173 RA complications, 105–106 plantar hyperkeratosis, 151, 152 Sickness Impact Profile, 180 injections in, 121–122 radiography, 101 Stanford Health Assessment intra-articular disease, 100–104 surgical management, 162–163 therapy, 121–130 Fransen, M, 20 Questionnaire see Health Fries, JF, 4 Assessment Questionnaire (HAQ) fulminating sensorimotor polyneuropathy, ‘Timed get up and go’ test, 177 treatment, lack of, 4 70 validation processes, 175 functional entheses, concept, 64 see also foot disease; joint diseases functional limitation, and muscle weakness, 93

208 INDEX functional status H I Berg balance test, 177 clinical features of foot, 63–64 hallux abnormalities, in RA, 12–13, 45, 59, ICD-10 (International Statistical MACTAR instrument, 176–177 83–84 Classification of Diseases and measurement, 169–170, Related Health Problems), 7 174–178 hallux abductovalgus (HAV) deformity, patient-completed measures, 175, 177 83–84 ICF (International Classification of Stanford Health Assessment Functioning, Disability and Health), Questionnaire see Health Hallux Metatarsophalangeal-Inter- 2, 7–9, 59, 170 Assessment Questionnaire (HAQ) Phalangeal (HMTP-IP), 83 Steinbrocker scale, 177 component structure, 171 ‘Timed get up and go’ test, 177 hallux rigidus, 12 footwear, 148 validation processes, 175 hallux tortus, 12, 13 treatment, 131, 132, 148 variability of, 176 hallux valgus, 12, 107 ICIDH (International Classification of hammer toes, 60 G hand joints, 9 Impairments, Disabilities and HAQ see Health Assessment Questionnaire Handicap), 7 Gadolinium-DPTA, 173–174 IL-17 (interleukin-17), 6 gait analysis, 17–55 (HAQ) imaging of foot and ankle, 3, 9, 99–112 Harrison, BJ, 3 complications of RA, 105–106 algorithms, 20, 41 HAV (hallux abductovalgus deformity), computerized tomography, 164, 173 benefits, 30 extra-articular disease, 104–106 case study, 22–24 83–84 importance, 99–100 critics of, 19 Health Assessment Questionnaire (HAQ) intra-articular disease, 100–104 definition, 17 joint and tissue change, 173–174 energy consumption, 52 development, 4 3-D see 3-D images foot function, 18–19 early disease, 62 see also MRI (magnetic resonance footfall pattern, 21 functional status, 176 joint kinematics, 25–34, 26 gait analysis, 20 imaging); U/S (ultrasound) joint kinetics, 35–40 and Leeds Foot Impact Scale, immune complexes, 7 multi-segment foot analysis, 14 immunoglobulins, 173 muscle function, 51–52 183 indicators, process and outcome, 4 observational, 19–20 multidimensional nature, 176 infection, 105–106 and pes planovalgus deformity, 26, 27, 29, Personal Impact, 171 health status intra-articular therapy, 123 30, 48, 58 concept, 170 inflammation plantar pressure distribution see plantar measures, 169–170, 178 erythema, 88 pressure distribution composite, 183–184 extra-articular disease, 104 referral from multidisciplinary team, disease-specific, 180–181 forefoot, 12 generic, 179 sesamoid bones, 59 17–18 region specific, 181–183 small joint, 9 spatial and temporal parameters, 20–25, health-related quality of life, concept, and stiffness of joint, 61 sub-talar joint, 58 21, 22, 48 170–171 synovial, 57, 59, 106 and specific impairments, 24 heel techniques, application in RA, 19–51 see also synovitis utility of, 26 ethesitis sites at, 64 infliximab, 118 walking speeds, 24 plantar (rearfoot), 88–89 infrared thermography, 88 walkway systems, 20–21, 22 heel lift, delayed, 26, 28 injections gait training and re-education, 151 Helliwell, PS, 61, 71 GALS (Gait, Arms, Legs and Spine) high-risk foot, 152–155 of bursae, 126 service provision, 196 first metatarsophalangeal joint, 125 screening system, 17, 19, 75, 76 hindfoot in foot and ankle, 121–122 ganglia, detection, 105 disease, 107–108 intra-articular, 123–125 ganglion cysts, 105 surgery, 162 lesser metatarsophalangeal joints, 125 Garrow, AP, 182, 183 surgical management, 164–165 ‘Morton’s interdigital neuroma’, 127 gastro-intestinal ulceration, and NSAIDs, see also rearfoot peroneal tendons, 127 HLA molecules, Class II, 6, 7 proximal inter-phalangeal joints, 115 HMTP-IP (Hallux Metatarsophalangeal- Gede, A, 148 125, 126 gender, impairment, affecting, 62 Inter-Phalangeal), 83 rheumatoid nodules, 128 genetic factors, 7, 113 Hoffman’s procedure, metatarsophalangeal of soft tissues and tendon gold salts, 116–117 Graham, C, 163 joints, 162 sheaths, 126–130 Grennan, DM, 162 homocysteine, and macrovascular disease, sub-talar joint, 124–125 GRF (ground reaction forces), 35, 36, 37, 41 talo-crural joint, 124 ground reaction forces (GRF) see GRF 68 talo-navicular joint, 125 hosiery, padded, 51 tarsal tunnel, 128 (ground reaction forces) HRUS (high-resolution ultrasound), tibialis posterior tendon, 127 insoles, 142 174 insufficiency fractures, 106 hyaluronic acid, 123 inter-phalangeal claw, 13, 43 hydroxychloroquine, 117, 119, 120 hyperkeratosis, 151, 152 hyperviscosity syndrome, extra-articular disease, 71

INDEX 209 inter-phalangeal joints joints Locke, M, 24 injections, 125, 126 calcaneocuboid, 107–108 Long Term Conditions Policy (Department metatarsal joint disease, 107 cracking of, 90 surgical management, 162, 163 disease of see joint diseases of Health), 190, 191, 192, 194, 196 see also metatarsophalangeal joints function, 58 longitudinal surveys, 9 inter-phalangeal, 107 lymphocytes, 6, 7, 71 interferon gamma, 6 injections, 125 interleukin-17 (IL-17), 6 surgical management, 163 M internal moment, and gait analysis, 37 metacarpophalangeal (hand), 9, 12 International Classification of Functioning, metatarsophalangeal see McGonagle, D, 64 metatarsophalangeal joints McGuigan, L, 69 Disability and Health (ICF) see ICF mid-tarsal, 11 McIntosh, E, 5 (International Classification of movement of see joint movement macrophages, 6 Functioning, Disability and Health) painful, 79 McRorie, ER, 155 International Classification of Impairments, stiffness of, 60–61, 82 macrovascular disease, 67–68 Disabilities and Handicap structure, 58 MACTAR instrument, functional status, (ICIDH), 7 sub-talar see sub-talar joint International Statistical Classification of swollen, 79, 106 176–177 Diseases and Related Health see also swollen joint count magnetic resonance imaging see MRI Problems (ICD-10), 7 talo-crural, 10, 124 interphalangeal joints, hand, 9 talo-navicular see talo-navicular joint (magnetic resonance imaging) intra-articular disease, 100–104 tender see tenderness Manchester Foot Pain and Disability erosions, detection, 100, 101, 102 valgus, 163 joint effusion, detection, 104 Questionnaire (MFPDQ), 182, 183 synovitis, detection, 100, 102, juxta-articular osteoporosis, 106 Mander index scores, and enthesopathy, 103, 104 K 64 intra-articular ligaments, 58 markers intra-articular therapy, 121–130 Kager’s triangle, 109 Kaiser Permanente Triangle, 192, 193 acute phase, 77, 79, 173, 183 adverse effects, 123 Katz Index, and functional status, 176 biological, 3 drugs, 123 Keenan, MAE, 10–11, 24 diagnostic, 7 general principles, 121–122 Keller’s procedure, metatarsophalangeal evaluation of disease progress, 173 IPK (plantar keratosis), 162 immunogenetic, 4 joints, 163 severity, 6 J keratin, antibodies to, 3 Marshall, RN, 26 kinematics, 11 masses, peri-articular, 105 Jacobi, RK, 12 Masson, EA, 135, 152, 153 joint counts (swelling and tenderness) joint, 25–34, 26 MDFC (multidisciplinary footwear clinic), kinetics, joint, 35–40 EULAR handbook, 82 149 pain assessment, 77 L Medical Outcomes survey (SF-36), 178, recording, 80 suggested, 81 Lanzillo, B, 68 179 swelling, 79, 174 Larsen index, radiography, 173 medications see drug management joint diseases Leeds Foot Impact Scale (LFIS), 8, 182–183 mental health problems, and RA, effusion, detection, 104 Leeds gait laboratory, 18, 27 metatarsal, 106–107 Leeds rheumatology foot clinic, 135, 139, 62–63 synovitis see synovitis mepivicaine, 128 see also evaluation of disease progress; 142, 196 mesentric artery obstruction, and Academic and Clinical Unit of foot disease mononeuritis, 70 joint kinematics, gait analysis, Musculoskeletal Nursing, 197 metacarpal squeeze test, 9 leflunomide, 117 metacarpophalangeal joints 25–34, 26 leg ulceration, 67 joint kinetics, gait analysis, 35–40 Lesser Metatarsophalangeal-Inter- hand, 9 joint loading radial side, synovitis and bone erosion at, Phalangeal (LMTP-IP), 83 excessive, 58 LFIS (Leeds Foot Impact Scale), 8, 182–183 12 and synovial inflammation, 57 lifestyle demands, 62–63 see also metatarsophalangeal joints see also forefoot: loading of ligaments, pathology, 104 metatarsal joint disease, 106–107 joint movement, 90, 93–94 lignocaine, 121–122, 128 metatarsal squeeze test, 9, 12, 43 joint ranges, summary, 91–92 Likert scale, and screening tools, 75–76 metatarsophalangeal (MTP) joints muscle weakness, assessing, LMTP-IP (Lesser Metatarsophalangeal- bursae at, 79 COP located at, 37 93–94 Inter-Phalangeal), 83 deformity, 83–84 joint space narrowing, 106, 107 local anaesthesia, 122, 130 early disease, 10 joint stiffness erosion, 106 clinical assessment, 82 case study, 22 definition, 61 first, 125, 163 early-morning, 60–61 forefoot symptoms, 131 inflammation, 58, 132 injections of, 125 kinematics, 27

210 INDEX metatarsophalangeal (MTP) (Continued) muscle weakness, 11 O lateral, 106 assessing, 93–94 lesser, 125 obesity, and RA, 62 pain in, 60, 148 muscles O’Connell, PG, 24 plantar pressure distribution pattern, clinical assessment, 84 oedema, bone-marrow, 100 42 disease of see Muscle disease OMERACT (Outcome Measures in radiography, 101 function (gait analysis), 51–52 retraction of, 43 size of, 93 Rheumatoid Arthritis), 14, 103, 114, squeezing of, 90 strengthening of, 150–151 172 surgical management, 162–163 OPG (osteoprotegerin), 7 synovitis, 12, 79 Myocrisin (sodium aurothiomalate), 116 Orthopedic Foot and Ankle Society (USA), tenderness, 79 83 see also inter-phalangeal joints; N orthoses, foot, 136–147 metacarpophalangeal joints accommodative devices, 140 nail abnormalities, 65 early disease, 136, 138–139 methotrexate, 117, 119, 120, 162 nail cutting, service provision, 196 established disease, 140 MFPDQ (Manchester Foot Pain and National Health Service (NHS) 189 footwear, 146, 148–150 National Institute for Clinical Excellence functional devices, 140 Disability Questionnaire), future of, 147 182, 183 (NICE), 116, in-shoe, 194 Michelson, J, 11 120 insoles, 142 mid-tarsal joints, 11 National Institutes of Health (USA), 26 material testing, 141 midfoot National Primary and Care Trust moulded, pre-fabricated devices, 142 assessment, 90 Development Programme orthotic management, 140–141 disease of, 107–108 (NATPACT), 194–195 pain management, 144 established disease, review, 11–12 National Service Frameworks (NSFs), 133, physical therapy, 144 scoring system, 83 194 plantar pressure distribution, 51 surgical management, 163–164 NATPACT (National Primary and Care rationale for use, 137 minocycline, 117 Trust Development Programme), rigid customized, 139, 141, 143 mobility problems, 60 194–195 service provision, 196 MOCAP (motion capture) systems, 27, 28 necrosis of bowel, and mononeuritis, 70 ‘soft-tissue substitution’, 12 models of care, 192–194 nefopam, 114 templates and casting, 142 multi disciplinary, 198–202 neovascularity, and tendinopathy, 104 treatment response, 142–147 mononeuritis/mononeuritis multiplex, 70 nerve blocks (foot and ankle), 128–130 see also footwear monozygotic twin disease, 7 peroneal nerve blockade, osmic acid, 123 mortality rates, and RA, 5 osteoarthritis, 58, 60 Morton’s interdigital neuroma, 58, 59, 69, common/superficial, 129–130 osteomyelitis, 155 127, 128 saphenous nerve, 130 osteoporosis, 106 MRC grading system, muscle weakness, sural nerve, 130, 131 osteoprotegerin (OPG), 7 93 tibial nerve blockade, 129 outcome indicators, 4 MRI (magnetic resonance imaging), 3, 9, nerves, saphenous and sural, 130 Outcome Measures in Rheumatoid Arthritis 99 neurological assessment, 95–96 (OMERACT), 14, 103, 114, 172 bursae, 105 neuropathies cysts, 105 compression, 68–69 P drawbacks, 174 distal sensory, 69–70 enthesopathy, 64 fulminating sensorimotor pain erosions, detection, 100 assessment of, 77–78, 95 false positives, 100 polyneuropathy, 70 forefoot, 106 forefoot region, 12 mononeuritis/mononeuritis multiplex, management of see pain management gait analysis, 19, 30, 32, 41 in metatarsophalangeal joints, 60, 148 as gold standard, 173 70 and rearfoot deformity, 13 hindfoot disease, 107, 164 and palsy, 70 stress, 90 joint effusions, 104 and vasculitis, 66 ligament assessment, 104–105 Neuropen/Neurotip, 95 pain killers 114, 128, 129 mid-tarsal region, 11, 12 neutrophils, 6, 7 pain management, orthoses, foot, 144 midfoot disease, 107 NHS (National Health Service), access to painful toes, 9 multiplanar imaging, 100 palsy, and neuropathies, 70 plantar fasciitis, 110 services, 189 paracetamol, 114 plantar pressure distribution, NICE (National Institute for Clinical pathogenesis, 6–7 pathomechanics see gait analysis 41 Excellence), 116, 120 patient education and self-management, tendon assessment, 104–105 NOAR (Norfolk Arthritis Register), 3 see also imaging of foot and ankle non-steroidal anti-inflammatory drugs 133–136, MTP joints see metatarsophalangeal joints 196 multi-segmental kinematic foot model, 26 (NSAIDS) see NSAIDs (non-steroidal patient group directions (PGDs), 197 multidisciplinary footwear clinic (MDFC), anti-inflammatory drugs) PCI (physiological cost index), Nordemar, R, 150 52 149 Norfolk Arthritis Register (NOAR), 3 multidisciplinary team, working in, 197–198 NSAIDs (non-steroidal anti-inflammatory muscle disease, extra-articular, 71 drugs), 52, 113, 114–116, 121 muscle testing, 85–87 COX-1 and COX-2 specific, 115, 116 side effects, 115, 116 NSFs (National Service Frameworks), 133, 194

INDEX 211 PCTs (Primary Care Trusts), 191 R reflexes, clinical assessment, 96 performance qualifiers, impairment, 8 reliability, and validation processes, 175 peroneal nerve, and compression RA (rheumatoid arthritis) REMS (Regional Examination of the causes, 6 neuropathies, 69 classification criteria, 2 Musculoskeletal System), 75, 76 peroneal nerve blockade, alternative classification tree method, 3 responsiveness, and validation processes, complexity, 2 common/superficial, 129–130 complications, imaging, 105–106 175 peroneal tendons, 35, 110 costs, 5–6 retrocalcaneal bursitis/bursae, 11, 65, pes planovalgus deformity, 10, 11 diagnosis, 2, 3 effects, 1, 169 109–110, 126 and gait analysis, 26, 27, 29, 30, 48, 58 employment issues, 5, 63 palpating for, 89 progression, 48 epidemiology, 2–3 rheumatoid arthritis see RA (rheumatoid rearfoot eversion, 30 foot-health care needs for sufferers, PGDs (patient group directions), 197 189–190 arthritis) phenylbutazone, 115 gender differences, 99 Rheumatoid Arthritis-specific Quality of PHQ (Podiatry Health Questionnaire), 181 genetic factors, role, 7, 113 physical therapy, orthoses, foot, 144 incidence of, 1, 2, 3 Life (RAQoL), 181 physiological cost index (PCI), 52 natural history, 4–6 rheumatoid factor, 3, 4, 7 piroxicam, 114 new onset, current optimal approach, ‘rheumatoid foot’, definition problems, plantar fascia, injection, 126–127 120 plantar fasciitis, 110, 129 and osteoarthritis, 60 1–2 plantar heel, rearfoot, 88–89 outcome, 5 rheumatoid nodules, 11, 70, 128 plantar keratosis (IPK), 162 pathogenesis, 6–7 plantar pressure analysis, 147 prevalence in population, 3 imaging of, 105 plantar pressure distribution risk factors, 3–4 rheumatology foot clinics, multidisciplinary and arthroplasty procedures, seropositive, 5 treatment see treatment early disease, 199 50 walking pattern of patients, 17 established disease, 199–200 clinical utility, 43–44 winter incidence, 9 primary care, 198–200 foot pressure distribution pattern, 43 referral indicators, 201 gait analysis, 41–51 radiation synovectomy, 123 secondary/tertiary care, 198, 200–202 measurement, 48, 51 radiocolloids, 123 rheumotoid factor, evaluation of disease peak pressure profiles, 45, 49 radiography plantar-flexed foot, 26 progress, 173–174 plasma viscosity, 173 benefits, 184 rice body bursitis, 105 Platto, MJ, 24, 83 erosions, detection, 100 risk factors, 3–4 Podiatry Health Questionnaire (PHQ), 181 forefoot, 101 podiatry management, conservative, Larsen index, 173 atherosclerosis, 68 MTP joint, 101 Ritchie, DM, 174, 183 131–155 plain film, 99, 100, 106, 107, 110, 173 rituximab (anti-B cell therapy), 119 foot orthoses see orthoses, foot Sharp score, 173 footwear, 146, 148–150 radiologist, role, 110 S muscle strengthening, 150–151 Rall, LC, 150 patient education and self-management, RAND corporation, SF-36 Medical SAC (surgical appliance clinic), 149 sagittal plane feature, ankle, 26, 133–136 Outcomes Survey developed by, skin and wound care, 151–155 179 39 Podiatry Rheumatic Care Association, 197 randomized-controlled trials, 117 saphenous nerve, 130 polyarthritis, early RA, 9 orthoses, 141, 143 Sari-Kouzel, H, 134 polymorphs, 121 RANKL (receptor activator of nuclear SCP (Society of Chiropodists and prednisolone, 162 factor ligand), 7 Prier, A, 197 RAQoL (Rheumatoid Arthritis-specific Podiatrists), 197 primary care, multidisciplinary Quality of Life), screening tools, 75–77 181 rheumatology foot clinics in, 198–200 rearfoot GALS (Gait, Arms, Legs and Spine) Primary Care Trusts (PCTs), 191 anterior and posterior regions, 88 screening system, 17, 19, 75, 76 process indicators, 4 clinical assessment, 88–89 pronation, sub-talar joint, 58 deformity, and pain, 13 self-management, 190 proprioception, 96, 150–151 established disease, review, 10–11 and education, 133–136, 196 pulmonary nodules, 65 eversion, in pes planovalgus, 30 pulses, palpation of, 94 lateral region, 89 self-management advice, 196 pyoderma gangrenosum, and ulcers, 67 medial region, 89 Semmes-Weinstein filaments, 95, 96 plantar heel, 88–89 sensitivity, and validation processes, 175 Q see also hindfoot seronegative spondyloarthropathies, 64, referral qualifiers, impairment degree, 8 and gait analysis, 17–18 117, 126 quality of life indicators for, 201 service provision, 194–197 suggested guidelines, 199–200 concept, 170 corn and callus reduction, 196 measures, 169–170 education and self-management advice, disease-specific, 180–181 196 Quality Metric, SF-36 publishers, 179 extended scope practice and surgery, 196–197 foot health and medical services, 189–192 general foot care, 196 inequity, 189 multidisciplinary team, working in, 197–198 nail cutting, 196 padding, 196 sesamoid bones, inflammation in, 59

212 INDEX SF-36 (Medical Outcomes survey), 178, 179 sub-talar joint, 108 tarsal tunnel, 69, 128 Sharma, M, 43 disease, 10, 26 TB (tuberculosis), 118 Sharp score, radiography, 173 inflammation, vulnerable to, 58 temperature, clinical assessment, 88, 96 Shi, K, 11 intra-articular injections, tenderness SI (Structural Index), 83 124–125 Sickness Impact Profile (SIP), 180 passive range of motion during clinical assessment, 79, 82 side effects examination, 30 EULAR handbook, description of counts structure and function, 58 anti-malarial drugs, 117 and talo-crural joint, 123 in, 82 anti-TNF drugs, 118, 119 ‘torque converter’ role, 31 recording of counts, 80 D-penicillamine, 117 suggested count, 81 intra-articular therapy, 123 suitability, and validation processes, and swollen joint count, 174 leflunomide, 117 175 tendinopathy, 104, 105 methotrexate, 117 Achilles, 108–109 NSAIDs, 115, 116 sulindac, 114 tendon sheaths, injection, 126–128 steroids, 119 sulphasalazine, 116, 120 tendons sulphasalazine, 117 MRI assessment, 105 Siegel, KL, 40 side effects, 117 pathology of tendons and ligaments, Sims, DS, 95 sural nerve, 130, 131 sinus tarsi, palpation of, 89, 124 surgical appliance clinic (SAC), 149 104–105 sinus tarsi syndrome, 108 surgical management, 161–167 peroneal, 110, 127 SIP (Sickness Impact Profile), 180 rupture of, 104 skin bilateral surgery, 162 tenosynovitis, 59, 69 assessment of, 84 forefoot, 162–163 tibialis posterior see tibialis posterior and wound care, 151–155 general considerations, smoking, as risk factor, 4 tendon SMP (FOOTSTEP self-management 161–162 see also tenosynovitis hindfoot, 164–165 tenosynovitis, 59, 69, 89, 90 programme), 134, 135, midfoot, 163–164 and ankle, 165 196 swollen joint count detection, 104 Society of Chiropodists and Podiatrists clinical assessment, 77, 79 `hypertrophic’, 121 (SCP), 197 EULAR handbook, 82 tarsal tunnel, 128 sodium aurothiomalate (Myocrisin), 116 recording, 80 tibialis posterior tendon, 127 soft tissues suggested, 81 see also tendons disease of, 108–110 and tender joint count, 174 thalidomide, 117–118 injection, 126–128 synovial cysts, 105, 108 Thomson, F, 135 and modifying factors, 62 synovial sheaths, 59 3-D images Morton’s interdigital neuroma, 127, 128 synovitis gait analysis, 19, 20, 27, 34, 39 plantar fascia, 110, 126–127 ankle, 88 joint and tissue change, imaging, 173 rheumatoid nodules, 128 bursae, within, 108 laser surface scanning, 147 swelling of, 106 detection, 100, 102, 104 mid-tarsal region, 12 tarsal tunnel, 128 tibial nerve blockade, 129 ‘soft-tissue substitution’, orthoses, 12 ultrasound, 103–104 tibialis posterior tendon, 10 specificity, and validation processes, 175 development, 57 attenuation, 58 Spiegel, JS, 10, 11 dorsal erosion associated with, 104 dysfunction, 32–33 Spiegel, TM, 10, 11 forefoot, 90 inflammation, 58 spondylarthropathies, and enthesopathy, inflammation, 57, 59, 106 injections, 127 64 joint kinematics, 25 midfoot and hindfoot disease, 107 squeeze tests, 9, 10, 12, 43 midfoot, 90 and neuropathies, 69 Stanford Health Assessment Questionnaire at MTP joints, 12, 79 rupture, 33 (HAQ) see Health Assessment presenting symptoms, 57–59 ‘Timed get up and go’ test, 177 Questionnaire (HAQ) temperature, elevation of, 88 Tinel’s sign, 89 Steinbrocker scale, and functional status, synovium, 6, 103 TNF see tumour necrosis factor 177 toes steroids, 109, 119 T clawing of, 46 and corticosteroids, 120, 121, 122 hammer, 60 ‘Morton’s interdigital neuroma’, T lymphocytes, 6, 7 inter-phalangeal joint, 107 tactile examination, 88–90 painful, 9 127 touch pressure, neurological assessment, 95 for neuropathy, 68 forefoot, 90 trainers, 60 stiffness, joint midfoot, 90 tramadol, 114 clinical assessment, 82 rearfoot, 88–89 treatment defined, 61 ‘tactile pavement’, 60 drugs see drug management early-morning, 60–61 talo-crural joint intra-articular therapy, 121–130 stress fractures, 107 disease, 10 podiatry management, 131–155 stress pain, 90 intra-articular injections, 124 timing, 192–194 stride length, and joint loading, 57 and osteoarthritis, 58 tuberculosis (TB), 118 Structural Index (SI), 83 and sub-talar joint, 123 tumour necrosis factor, 6, 162 sub-cutaneous nodules, 70 talo-navicular joint, 11–12, 107–108 drug treatment, 118, 119 injection of, 125 Turesson, C, 66 and RA, 58

INDEX 213 U United States visual inspection costs of RA, 6 foot posture, 84 U/S (ultrasound), 3, 9, 99 National Institutes of Health group, 26 footwear, 84, 88 artefacts, 104 Orthopedic Foot and Ankle Society, 83 joint deformity, 83–84 bursae, 105, 126 muscle, 84 cysts, 105 V skin, 84 Doppler, 3, 94, 102 erosions, detection, 100 Vainio, K., 10, 11, 65 Voskuyl, AE, 69–70 high-resolution (HRUS), 174 validation processes, functional status, 75 hindfoot, 164 Vane, Sir John, 114 W injections guided by, 122 varus deformity, 58, 164 joint effusions, 104 vascular assessment, 94–95 walkway systems, gait analysis, 20–21, 22 linear assay probes, 104 vasculitis, 65, 66, 67, 155 WHO (World Health Organization), mid-tarsal region, 11 plantar fasciitis, 110 and neuropathy, 69–70 International Classification of synovitis, 103–104 rheumatoid nodules, 70 Functioning, Disability and Health, tendon assessment, 104 steroid treatment, 68 2, 7–9 see also imaging of foot and ankle systemic, 70 Williams, A, 149 venous insufficiency, and leg ulceration, Winter DA, 39–40 ulcers Woodburn, J, 138, 139, 141 debridement, 129 67 wound care, 151–155 foot, 153, 154, 162 vibration, neurological assessment, 95–96 Yorkshire Early Arthritis Register, 174 iatrogenic, 154 video techniques, gait analysis, 20 leg, 67 visual analogue scales, footwear comfort, ultrasound see U/S (ultrasound) 88