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Foot orthoses are commonly prescribed by health professionals as a form of intervention for the symptomatic foot in rheumatoid arthritis. However, there is a limited evidence base to support the use of foot orthoses in this patient group. This article provides a critical review of the use of foot orthoses in the management of rheumatoid arthritic foot pathologies. A search was conducted in the Cochrane Controlled Trials Register (current issue of the Cochrane Library), Physiotherapy evidence database (PEDro), Medline, The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Allied and Complementary Medicine (AMED) and from reference lists in journal articles. The language was restricted to English. Searching of the databases was undertaken between December 2004 and March 2005. The results indicated there is no consensus of opinion on the choice of foot orthoses used for the management of pathology in the rheumatoid foot, although there is strong evidence that foot orthoses do reduce pain and improve functional ability. The type of foot orthoses used ranged from simple cushioned insoles to custom-made rigid cast devices. Methodological issues raised included small sample size and poor use of valid and reliable outcome measures. There is limited evidence pertaining to cost-effectiveness. The results indicated a need for further investigation into the most clinically and cost-effective foot orthoses to prescribe in the management of the rheumatoid arthritic foot. This review highlights the need to identify the various types of foot orthoses that are most effective in the management of the established rheumatoid arthritic foot.
The effect of foot orthoses in rheumatoid arthritis
E. de P. Magalhães*, M. Davitt, D. J. Filho, L. R. Battistella, and M. B. Bértolo
Objective. To evaluate the effectiveness of foot orthoses using the foot function index (FFI) in a group of patients with rheumatoid arthritis (RA) during a period of 6 months.
Methods. Thirty-six rheumatoid subjects with foot pain were examined and appropriate foot orthoses were prescribed according to each patient's needs. All the patients were evaluated 30, 90 and 180 days after the baseline visit. FFI values, daily time of wearing the orthoses and adverse effects were noted at each appointment. The Stanford Health Assessment Questionnaire (HAQ) was used at the initial visit to evaluate the influence of physical condition on FFI response.
Results. With the use of foot orthoses, FFI values decreased in all subscales (pain, disability and activity limitation). This reduction was noted in the first month and was maintained throughout the trial. Those using EVA (ethyl-vinyl acetate; n = 28) orthoses presented results similar to those for the total group. Patients wearing made-to-measure orthoses (n = 8) exhibited higher initial FFI values and worse evolution during the trial, significant for pain and disability but not for activity limitation. Minor adverse reactions were noted; none required interruption of treatment. There was no relation between HAQ and FFI evolution.
Conclusions. Foot orthoses were effective as an adjuvant in the management of rheumatoid foot. They significantly reduced pain, disability and activity limitation, as measured by the FFI, with minor adverse effects.
The Following User Says Thank You to Hylton Menz For This Useful Post:
Conservative management of foot problems in patients with rheumatoid arthritis (RA) may consist of the prescription of customised foot orthoses. Indications for foot orthoses are not clear and the effectiveness of the intervention is highly variable among patients. Knowledge on which patients benefit the most from foot orthoses can help to select patients eligible for this type of intervention. The objective of the present study was to determine clinical and demographic factors that predict the outcome of customised foot orthoses on pain and disability in patients with RA.
A total of 135 RA patients who were supplied with customised foot orthoses were included in this prospective cohort study. Pain and disability were measured before and after the intervention period using a Numeric Rating Scale (NRS) for foot pain, the Foot Function Index (FFI), the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) and a 10-meter walking test. The intervention period consisted of one or more appointments with the podiatrist during which the foot orthoses were customised. Swollen foot joint count, foot deformity scores, forefoot peak pressure, disease duration, age, gender, body mass index and baseline values of the outcome measures were selected as potential factors predicting outcome. Multivariate linear regression analyses were performed to determine factors associated with change in pain and disability (at P < 0.05).
Disease duration was negatively associated with the change scores in NRS foot pain (P = 0.018), WOMAC pain (P = 0.001), FFI disability (P = 0.003) and WOMAC physical function (P = 0.002). Age was negatively associated with the change score in 10 meter walking time (P = 0.008). For all outcome measures baseline values were positively associated with the change scores (P < 0.001).
Shorter disease duration predicted greater improvements in self-reported foot pain and disability, and younger age predicted greater improvements in walking time after intervention with foot orthoses. Also, higher baseline values of pain and disability predicted greater improvements. Referral for conservative management with foot orthoses in the early stage of RA seems important when aiming to achieve reduction in pain and improvement in daily activities.
Custom molded insoles with metatarsal supports are used to redistribute excessive loading under the metatarsal heads in patients with metatarsalgia. However, these pressure reductions are usually insufficient for the rheumatoid foot with painful deformed metatarsal heads. We developed an effective insole made by sequential foam padding under successive walking impression.
Seventeen consecutive rheumatoid arthritic outpatients with metatarsal pain participated in this repeated measures study of 7-mm flat Ethylene Vinyl Acetate, custom molded and dynamic impression insoles. Peak plantar pressure, pressure-time integral, contact area and mean force were measured by a Pedar-X mobile system. Pain levels were assessed using a Visual Analog Scale (0-10).
Compared to the Ethylene Vinyl Acetate control, the metatarsal head peak pressure and pressure-time integral were significantly reduced in dynamic impression insoles by 46.3% (P<0.001) and 48.9% (P<0.001), respectively. Compared to the custom molded insole, the dynamic impression insole significantly reduced 18.3% of peak pressure (P<0.001) and 20.1% of pressure-time integral (P<0.001) by increasing 8.1% of contact area (P=0.005) at the metatarsal heads, but there were no significant differences in all variables at the heel. After using the dynamic impression insole, the mean pain score was significantly reduced from 7.6 to 1.1 (P<0.001), and six participants experienced total pain-relief in walking.
Dynamic impression insoles effectively relieve metatarsal pain because of a larger weight-bearing area. Forefoot shape during walking should be taken into consideration in orthotic designs for maximum pressure reduction. Consequently, we recommend using materials with memory properties to dynamically accommodate painful metatarsal heads.
To identify and critically appraise the evidence for the effectiveness of custom orthoses for the foot and ankle in rheumatoid arthritis.
Studies were identified in appropriate electronic databases (from 1950 to March 2011). The search term "rheumatoid arthritis" with "foot" and "ankle" and related terms were used in conjunction with "orthoses" and synonyms. Included studies were quantitative longitudinal studies and included randomized controlled trials (RCTs), case-control trials, cohort studies, and case series studies. All outcome measures were investigated. Quality assessment was conducted using the Cochrane Collaboration criteria with additional criteria for sample population representativeness, quality of statistical analysis, and compliant intervention use and presence of cointerventions. Meta-analyses were conducted for outcome domains with multiple RCTs. Qualitative data synthesis was conducted for the remaining outcome domains. Levels of evidence were then assigned to each outcome measure.
The inclusion criteria were met by 17 studies. Two studies had high quality for internal validity and 3 studies had high quality for external validity. No study had high quality for both internal and external validity. Six outcome domains were identified. There was weak evidence for custom orthoses reducing pain and forefoot plantar pressures. Evidence was inconclusive for foot function, walking speed, gait parameters, and reducing hallux abductovalgus angle progression.
Custom orthoses may be beneficial in reducing pain and elevated forefoot plantar pressures in the rheumatoid foot and ankle. However, more definitive research is needed in this area.