SALFORD, UK—Based on input from focus groups, structured interviews, and questionnaires, shoes designed for rheumatoid arthritis (RA) patients were more acceptable to them than traditional therapeutic shoe designs. The specially designed shoes were worn more often and were more effective in reducing pain, disability, and physical limitations, according to a clinical trial published in the February issue of Rheumatology.¹  Structural and functional changes in the feet of RA patients are known to affect gait and mobility, impacting the patient's quality of life, but a 1999 study shows that rheumatologists rarely examine RA patients' feet and even more rarely talk about their shoes.²

"The new shoe incorporated several features that were identified by the patients as being their preferred features of footwear," lead researcher Anita E. Williams, PhD, from the Center for Rehabilitation and Human Performance Research at the University of Salford, in the UK, writes. "These [features] included the shape of the front of the shoe, design of the heel and sole unit, the quality of leather and linings, ease of donning and doffing, height of the heel, and thickness of the sole unit."

"Patients will be more likely to wear shoes with which they are satisfied with the comfort, fit, appearance and long term function and only then will long-term foot health benefits be achieved," Dr. Williams adds.

Avoiding stigma is important to patients

Dr. Williams points out that footwear "has the potential to hide or to emphasize foot deformity and the presence of disease" and that "the potential for footwear to identify some as having deformity, disease, and disability should not be trivialized, nor should the importance [that] a patient may place on this."

The new footwear study enrolled 80 patients who had RA for 5 or more years and who had foot deformity, difficulty in finding retail footwear, and self-reported foot pain. Half of the study participants were randomized to receive the "new design" shoes based on RA patients' input, while the other half were randomized to receive traditional therapeutic shoes currently used in the UK. The new shoe incorporated a firm contoured sole. By contrast, the traditional shoe had a flat insole of 6 mm low-density polyethylene foam and 3 mm of open cellular polyethylene memory foam.

Study participants were meant to complete two health-related quality-of-life scales (Foot Health Status Questionnaire and the Foot Function Index) at baseline and after 12 weeks. The first sign of success for the new design was that only nine of 40 patients from the traditional shoe group were still around to complete the week 12 assessment versus 27 of 40 patients from the new shoe group. Nine of the 22 "traditional shoe" drop-outs withdrew because they did not like the shoe design versus only one of the 12 "new shoe" drop-outs.

Thirty-four participants withdrew from the study after the footwear was supplied because of both related and nonrelated footwear problems. Of these 34 patients, four died during the study, and one died before the footwear had been fitted; another five patients withdrew because of unrelated health problems; three withdrew for work or travel problems. 

The researchers suggest that the high drop-out rate is not a limitation, per se. "It reflects the clinical reality that many patients choose not to wear the footwear they are provided with," they explain.

Patients randomized to the new shoe design showed significant improvement from baseline to week 12 in the specific health-related quality-of-life scales versus their counterparts in the control group (P <.05). There was no significant difference in both specific health-related quality-of-life scales after week 12 between the two groups (P >.05).

The new study "clearly demonstrates that it is possible to improve the foot health status in patients with RA with specialist therapeutic footwear, which meets patients' criteria," the researchers conclude. "Clinicians who refer patients for specialist therapeutic footwear should be aware that there are a wide range of footwear designs and any recommendation should seek to address the clinical and personal needs of the patient."

Treating the RA foot

In many practices, however, considerations of shoe design and examinations of the foot are not routine elements of RA clinical care. Valerie K. Branch, MS, of the University of Texas Southwestern Medical Center at Dallas, and colleagues have reported that rheumatologists often bypass the foot when performing musculoskeletal examinations. In the study, the performance of 21 rheumatologists was evaluated by arthritis educators (trained patients who had RA) and compared with that of internal medicine residents. Only half of the rheumatologists palpated the metatarsophalangeal, proximal interphalangeal, and distal interphalangeal joints, and only 13% checked midfoot motion or observed gait in the RA patients.²

Cary M. Golub, DPM, FACFAS, a podiatrist in private practice in Long Beach, New York, told CIAOMed that he sees many RA patients. "Sometimes, I'm the one that makes the diagnosis after a primary complaint of bilateral foot pain, [and] a blood work-up confirms the diagnosis," he said. "I usually then send the patient to a rheumatologist to be treated systemically, and I treat their podiatric complaints."

"The foot pain can be relieved by oral anti-inflammatory medications, oral steroids, steroid injections into the joint, immobilization, including casting, and modification of footwear," Dr. Golub said. "I agree with Dr. Williams that custom footwear does play an important part [in] relieving the pain in a RA patient."

E-mail any comments to .

References

1. Williams AE, Rome K, Nester CJ. A clinical trial of specialist footwear for patients with rheumatoid arthritis. Rheumatology. 2007;46:302-307.
2. Branch VK, Graves G, Hanczyc M, et al. The utility of trained arthritis patient educators in the evaluation and improvement of musculoskeletal examination skills of physicians in training. Arthritis Care Res. 1999;12:61-69.