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Objectives. The structural and functional changes in the RA foot often affect the patient's gait and mobility, impacting on the patient's quality of life. Successful management of these foot pathologies and resultant problems can involve the provision of specialist therapeutic footwear. The aim of the study was to evaluate the value of a new footwear design based on patients' opinions compared with a traditional footwear design.
Method. A total of 80 patients with RA of 5 yrs or more duration, foot deformity, difficulty in being able to obtain suitable retail footwear and self-reported foot pain were recruited. Patients were randomly assigned to either an intervention group (new design) or the control group (traditional design). Patients completed two specific health-related quality of life scales (Foot Health Status Questionnaire and the Foot Function Index) at baseline and after 12 weeks.
Results. Only 36 patients completed the trial. Ten refused the footwear outright and 34 withdrew from the study after the footwear was supplied, due to either non-footwear related problems or reasons related to the footwear. Both the specific health-related quality of life scales demonstrated significant improvement from baseline to week 12 with the intervention group (P < 0.05). There was no significant difference in both specific health-related quality of life scales after week 12 with the traditional group (P > 0.05).
Conclusions. Improvement in pain and patient satisfaction with the new design of footwear for patients with RA over the traditional design indicates the importance of patient involvement in the design process and throughout the process of supplying and monitoring the footwear. The fact that the new-design shoe was based on patients' involvement in the design process in a previous study may be the most important factor in its success. In order to meet the clinical goals of this footwear the patients need to wear them, and to achieve this the patients' requirements need to be acknowledged.
Many patients with RA are ferred to us for footwear +/- modifications.
We have no emperical evidence but the anecdotal evidence suggests that shoe design is the ovewhelming objection to prefabricated medical grade footwear. Making the patient comfortable with appropriate footwear is easy. Putting square pegs into round holes is the challenge. What we realy need is an orthopaedic high heeled sling back stilletto and we will be the champions of the RA foot
footwear and insole as a single therapeutic intervention
I was interested to read that the new footwear design which was found to be favourable had a contoured insole, compared to the traditional shoe which had a flat cushioning insole. I do agree that the footwear and insole should be considered as a single therapeutic intervention, however, I do believe that the contributions of the insole and footwear can be separated out, to distinguish the true effectiveness of the shoe. The reason that I would argue that this is important is because is it not often the case that when RA patients are prescribed a functional foot orthosis, the insole which comes with the shoe is removed, so that there is enough space to accomodate the prescribed device? So, I would be interested to know if the new design shoe is still more effective than the traditional design, with the insoles removed. Is the therapeutic effect of the shoe because of the insole, or does it have its own therapeutic merits when considered without the insole? If the insole determines the shoes effectiveness, surely one shoe is not any better than the next. What do you think? (This is my first time on the forum so please be gentle with your responses!)
'V'
My own interpretation of this research is that it is the patient involvement in the process rather than purely the mechanical aspects of the footwear. (However I am unable to get a copy of the full research at the moment to commnet directly on it.)
I work in a situation where time is no issue, so when patients are prescribed footwear, they have input into the cosmetics of the shoe with compromises being made on both sides. This results in excellent patient satisfaction so far.
I think your question re the importance of a contoured insole is a good one and I would be interested in knowing peoples thoughts.
Patients with diseases which impact on foot health, for example diabetes and rheumatoid arthritis, are known to have some benefit from prescribed stock footwear with regards to clinical outcomes. Achieving this is not just about getting the footwear designed and fitted to meet the clinical needs, but it also requires that the patient wears the shoes. This means meeting the non-clinical needs or criteria of patients. The aim of this study was to compare perceptions of the same footwear between patients with diabetes and patients with rheumatoid arthritis (RA) with regard to specific design features. Fifty-four patients with RA and 40 patients with diabetes who required prescription footwear were asked to identify issues of importance, and to assess the features of five different pairs of stock footwear using a Likert scale scoring form. There was a difference between the RA and the diabetes groups with regards their overall requirements from the footwear with comfort being a priority in RA and style a priority for diabetes. Both groups rated the same footwear as overall best from the selection, but the scores suggest that there were features with the 'best' shoe which were not acceptable suggesting that even the 'best' shoe was a compromise This possibly indicates that existing footwear ranges do not meet all the patients' requirements. Patients have different perceptions with regard to what is important to them in terms of footwear with regards to the specific features of the footwear and one of the influences appears to be the underlying systemic disease. Patient-based criteria may be an important consideration in the design of the footwear
Reducing plantar pressure in rheumatoid arthritis: A comparison of running versus off-the-shelf orthopaedic footwear
Kym Hennessy, Joshua Burns, Stefania Penkala Clinical Biomechanics. In Press
Quote:
Background
Foot pain in patients with rheumatoid arthritis is common and can be associated with excessive forefoot plantar pressure loading. Running and off-the-shelf orthopaedic footwear are commonly recommended to manage foot pain and discomfort in these patients. The aim of this study was to evaluate the effect of running footwear as an alternative to off-the-shelf orthopaedic footwear on plantar pressure loading characteristics in people with forefoot pain associated with rheumatoid arthritis.
Methods
Twenty participants diagnosed with rheumatoid arthritis reporting chronic forefoot pain participated in this experimental, randomised, single-blind, cross-over trial of three footwear conditions: control, running and off-the-shelf orthopaedic. Outcome measures included measurement of peak pressure and pressure-time integral, with an in-shoe plantar pressure measurement system, beneath the total foot, forefoot, midfoot and rearfoot. Furthermore, perceived comfort and footwear acceptability were determined for each footwear condition.
Findings
Compared to the control footwear, forefoot peak pressures were reduced by 36% in the running footwear and by 20% in the orthopaedic footwear, compared to the control (P<0.001). Forefoot pressure-time integrals were reduced by 33% in the running footwear and by 23% in the orthopaedic footwear (P<0.001). The largest reductions were achieved with the running footwear across the whole plantar surface of the foot. Perceived comfort did not differ between running and orthopaedic footwear, although both were significantly more comfortable than the control footwear. Overall, more participants nominated the running footwear as the most acceptable footwear condition.
Interpretation
The results of this preliminary study show that running footwear was most effective at reducing plantar pressure loading and was regarded as a comfortable and acceptable footwear alternative by participants with forefoot pain associated with rheumatoid arthritis.
I'm not a podiatrist. I am a nurse and came to this site to prove a point that the Croc brand of footwear is ideal for nurses as they are comfortable, washable, they allow the feet to breathe and resist bacteria. However my NHS trust has taken it into their heads that they are unsuitable and have banned them. I could do with some expert backing to change their minds as 90% of the staff where I work are wearing them and rave about them. Incidently I first went on an artheritis site and artheritis sufferers are also raving about them and many rate them 10/10. Could someone please give me the professional ammunition I need to change minds. Jackie Suffolk UK
I personally do not like them as there is absoluely no torsional strength in this product and no support. Furthermore, there is only one width in this shoe which does not cater for a narrow or very wide foot. There is no room for a foot orthoses, and the shoes cannot be modified. The perforations on the vamp will allow "fluids" to enter the shoe. I had one client with a slim foot who advised me that her foot kept on moving from side to side and she asked my advice as to how to prevent this. The implications for this on foot pathology does not need an explanation.
This place for this shoe(everything else being equal) is for casual informal wear but not for industrial use.
Background
Specialist 'therapeutic' footwear is recommended for patients with diseases such as rheumatoid arthritis (RA) as a beneficial intervention for reducing foot pain, improving foot health, and increasing general mobility. However, many patients choose not to wear this footwear. Recommendations from previous studies have been implemented but have had little impact in improving this situation. The aim of this study was to explore RA patients' experiences of this footwear to ascertain the factors which influence their choice to wear it or not.
Method
Ten females and three males with RA and experience of wearing specialist footwear were recruited from four National Health Service orthotic services. Semi-structured interviews were carried out in the participants own homes. A hermeneutic phenomenological analysis of the transcripts was carried out to identify themes.
Results
The analysis revealed two main themes from both the female and male groups. These were the participants' feelings about their footwear and their experiences of the practitioner/s involved in providing the footwear. In addition, further themes were revealed from the female participants. These were feelings about their feet, behaviour associated with the footwear, and their feelings about what would have improved their experience.
Conclusions
Unlike any other intervention specialist therapeutic footwear replaces something that is normally worn and is part of an individual's body image. It has much more of a negative impact on the female patients' emotions and activities than previously acknowledged and this influences their behaviour with it. The patients' consultations with the referring and dispensing practitioners are pivotal moments within the patient/practitioner relationship that have the potential to influence whether patients chose to wear the footwear or not.
l find our RA clients are amongst the most compliant of all our clients with few exceptions, we put 90% into custom footwear and 60% (maybe more) also go into TCI's(we may only see the real bad ones?) they just love picking out styles and the colour leather they want.
Its hard to find an off the shelf shoe that is tight enough on the heel yet accommodates these other altered features of the forefoot that we see with RA.
Two clients l saw last night are sisters. 1st sister,foot length 235mm, heel width 65mm, Met width 105mm, Depth 1st MP 40mm.
2nd sister foot length 255mm, heel width 65mm, Met width 115mm, Depth 1st MP 40mm
We tend to build an accomadative shoe with a rocker sole which off loads the fore foot and helps redirect the "Push off point"reducing the abduction of the foot, but it is often the TCI that helps to recreate that trans metatarsal arch taking pressure of the met heads, especially the head of the often troublesome 2nd MPJ.
l dont know that you can separate the two items for the more serve clients if you want a positive outcome?
For those that want to see the image of the first sisters foot it is at the bottom of my home page, we have written consent
Do you angle the rocker peak point to match the 1st to 5th angle?
I have found that if this is not done then the 5th can get over loaded.
Your opinion about this and any other Rocker 'tweaks' would be great fully received.
l am sure there are others here that do more of this work than l do but for me it really is a case by case assessments process.
Some of the guiding factors are ROM's available from as far away as the hip or closer at the STJ. all things okay l dont always align 1st to 5th it can adduct the foot in some of the weaker muscle cases, then again l dont see all the clients and their gait as some are just documents posted/Emailed to me.
You really need to know the reason for the abduction, was it because the MPJ's where just so sore at Extension or not able to extend, or is the STJ really painful to dorsiflex/Plantaflex
If for the last 15years(?) they have been coming off the midfoot (foot really abducted) it maybe difficult to push that foot around as the hip may have become involved and the rocker may have to be placed at that almost midfoot/abducted line, l have done this only a few times when there was no choice as the standard rocker caused to many problems further up.
If STJ needs help a sash heel is a good idea for the elderly/frail otherwise a mild heel rocker is done.
How do you handle your clients?
My approach tends to be more symptom specific. Usually with a Rocker I am trying to accelerate the CoM or CoP in an attempt to 'un-load' the damaged tissues. The orientation of the rocker peak is usually based on there current propulsive phase mechanics - if they are propelling through the 1st then then a 90 degree angulation is used. If more 4th-5th then closer to 80 degrees.
I have found that the pain caused by incorrect angulation seems to be overloading of a structure not used to it - maybe they will get used to it but again I tend to concentrate on one thing at a time as I can't always address the global lower limb mechanics.
I don't usually need to use SACH heels as I find that if the Rocker is balanced via the heel raise, the patient is ok. I do use SACH and similar to try and decelerate PF moments at heel strike in attempt to slow down forefoot loading - verdicts out on that one at the moment.
Randomized controlled trial for clinical effects of varying types of insoles combined with specialized shoes in patients with rheumatoid arthritis of the foot.
Cho NS, Hwang JH, Chang HJ, Koh EM, Park HS. Clin Rehabil. 2009 Apr 29. [Epub ahead of print]
Quote:
Objective: To determine the effects of specialized shoes with insoles in patients with rheumatoid arthritis and the differences in terms of type of insole and anatomical location of foot pathology.
Design: Single-blinded randomized controlled trial.Setting: Outpatients of physical medicine and rehabilitation clinic at university hospital.Subjects: Forty-two patients with rheumatoid foot lesions were randomly assigned to two different orthotic intervention groups. The anatomical locations of the foot lesions were recorded (hindfoot or forefoot).Intervention: Participants were provided with an extra deep forefoot-rockered shoe and either a custom-made semi-rigid insole or a ready-made simple soft insole. They wore the provided footwear for at least 3 hours a day over six months.
MAIN OUTCOME MEASURES: Primary outcome measures were foot pain visual analogue scale (VAS) scores and Foot Function Index (FFI). Secondary outcome measures were erythrocyte sedimentation rate and C-reactive protein levels in blood, amounts of medications and active joint counts. These were checked at baseline and post intervention.Results: Eight patients dropped out at follow-up after six months of treatment. At six-month follow-ups, VAS scores and total Foot Function Index scores had decreased significantly in both groups versus baseline but intergroup comparison showed no significant differences in view of type of insoles and anatomical locations of foot pathology.
Conclusions: We were unable to identify differences between the types of insoles in terms of their clinical effects or between anatomical locations of foot lesions in the two groups, but both groups improved. Therapeutic shoes plus soft insoles might be effective enough in terms of foot pain and foot function for specific patients with rheumatoid foot problems regardless of the location of foot pathology.
Footwear and rheumatoid arthritis
footwear and insole as a single therapeutic intervention
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