Ep 28. GUIDELINES - BSR foot health in inflammatory arthritis guideline

BSR has published a new guideline for the assessment and management of foot problems in adults, children and young people with inflammatory arthritis.

Foot problems are almost universal in people with inflammatory arthritis, and virtually all people with inflammatory arthritis will experience foot problems at some point in the course of their disease. Despite this, we know that there is considerable unmet need. The guideline will cover foot problems in a number of different rheumatic conditions, including rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis and juvenile idiopathic arthritis.

 
Join guideline working group Chair, Edward Roddy, members Lara Chapman, Gavin Cleary, and expert by experience member, Alan Rawlings, in a roundtable discussion hosted by Prof Ernest Choy.

Read the full guideline and download the summary pdf here. 

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Transcript

You're listening to the Talking Rheumatology podcast, brought to you by the British Society for Rheumatology.

Ernest Choy:  0:15  

Hello and welcome to today's Rheumatology Roundtable, where we will dive into the new BSR guideline for the management of foot health in inflammatory arthritis. I'm Ernest Choy, Editor In Chief of Rheumatology, Oxford, and joining me today are a number of key members in the working group who developed this guideline, and I would like to ask them to introduce them to you. So, Alan.

Alan Rawlings:

Hi, Alan Rawlings, I'm what's known as, I suppose, an expert by experience. I've had rheumatoid arthritis for 36 years, much of which has affected my feet, obviously. 

Ernest Choy:

And then, Lara. 

Lara Chapman:

Hi, I'm Lara Chapman. I'm a podiatrist and a doctoral research fellow at the University of Leeds, and I'm lead author of the guideline. 

Ernest Choy:

And, Ed. 

Edward Roddy:

I'm Ed Roddy. I'm an academic rheumatologist from Stoke on Trent working at Keele University, and I'm the Chair of the guideline working group.

Ernest Choy:  1:20  

And last, but not least, Gavin. 

Gavin Cleary:

Hi, I'm Gavin Cleary. I'm a paediatric rheumatologist at Alder Hey Children's Hospital in Liverpool, and I've been on the working group to represent children and young people. 

Ernest Choy:

Fantastic. Welcome all of you. And, yes, you can see from the membership of the panel this guideline is going to be relevant to all people, both adults and children. So, Ed, can you start by giving us an overview of the guideline, why it is important and what does it include?

Edward Roddy  1:53  

Okay, so I'll start off with the why is it important. So we know that foot problems are almost universal in people with inflammatory arthritis, and virtually all people with inflammatory arthritis will experience foot problems at some point in the course of their disease. Despite this, we know that there is considerable unmet need. People with inflammatory arthritis often feel that their foot problems are ignored by healthcare professionals. We know that care pathways are frequently fragmented and inefficient, and there are often delays in accessing specialist care, such as podiatrists and orthopaedic surgeons. So, like many BSR guidelines, this is a whole life-course guideline, and it will cover foot problems in a number of different rheumatic conditions, including rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis and juvenile idiopathic arthritis. And what we hope to offer are recommendations for the assessment and management of foot problems in adults, children and young people with inflammatory arthritis. 

Ernest Choy:

Thank you. Lara, could you explain a little bit about how the guideline was developed? 

Lara Chapman:

We had a multi professional guideline working group, which included rheumatologists, podiatrists, a GP, a nurse, orthotist, orthopaedic surgeon and physiotherapist, as well as patients. The first thing we did was develop a guideline scope. So that involved establishing the questions that we wanted the guideline to answer. And we had support from a systematic review team at Keele University. So they helped us find and appraise all of the evidence relating to foot health and inflammatory arthritis, and then we discussed that evidence and formulated recommendations in meetings, in guideline working group meetings. 

Ernest Choy:

Great. So can you give us an overview of some of the key recommendations from the guidelines? 

Lara Chapman:

For assessment and diagnosis, key recommendations are that in patients with suspected or confirmed inflammatory arthritis, questions about foot symptoms should be asked at each visit, and then, if appropriate, a clinical examination of the foot should be carried out. And also that referral to specialist foot services, ie podiatry, orthopaedics, orthotics, should be considered at any stage of the disease course where foot problems are having significant impact. And then, in relation to personalised care, we make recommendations that individually tailored, culturally sensitive, foot health education and self management advice should be offered at diagnosis and on an ongoing basis by any member of the rheumatology MDT, and we provide guidance on what that education and advice should include. And then two of the key recommendations for treatment are that patients should have access to customised orthosis, so the orthoses that are recommended or prescribed by a health professional and local steroid injections can be offered as an adjunct for the relief of foot pain and inflammation. 

Ernest Choy  5:00:

Fantastic. Alan, as one of the Experts by experience in the guideline working group. Can you explain how you were involved and how you think this guideline may help people with problems with inflammatory arthritis? 

Alan Rawlings  5:32  

I was invited by Ed and a consultant rheumatology nurse to apply to become part of the guideline working group, and, right from the word go, after Ed spent a lot of time explaining to me how this whole process works, I was involved, and, again, in those early days, listening to the incredible and extraordinary amount of work that had gone into looking at the research that was available and how relevant it was, and then following that on and listening to the experts that had been gathered on the guideline working group. It was awe-inspiring from a patient's perspective, to know the degree of detail that had gone into this. 

And there was one particular item that came into it, which has suggested that every single consultation with either a consultant or a medical expert of some description, should involve foot problems, and I truly believe that will make a huge difference.

But it but it's also the fact that wherever one has the consultation, wherever one has treatment, one knows that with the guidelines in the background, then the best of all possible treatment can be given. By experience these people have put together something that we, as patients, can only benefit from.

Ernest Choy  7:11:

Fantastic. Gavin. I want to come to you because Alan has just said how the guidelines will help adults with foot problem in inflammatory arthritis, but the guideline covers people of all ages. Can you explain a little bit of how you and the working group members ensured the guideline will support children and young people?

Gavin Cleary  7:25  

As Ed alluded to at the start, the foot can be as frequently affected in children and young people with JIA as it can across the life course. So the guideline was extremely timely, really, just to promote some of the messages that we've already heard of - of the importance of assessing that the foot, in all assessments of children presenting with JIA. Sadly, I think there is, there is a particular susceptibility to damage in the foot in JIA now, of course, that that will be driven by the inflammatory process. But there may be some particular factors relevant to children around, load bearing around, of course, the child who's growing may have some particular complexity of assessment of this area.

I was very reassured from the outset, as Lara explained, that the voice, the relevance, of this guideline to children, young people, was really clear, and this group were clearly focused upon throughout all aspects of the guideline, and that included through medical assessment, through diagnosis, through medical management, but very much about the multi disciplinary approach to management, and I was very assured and reassured throughout that the voice of children, young people was heard. 

Ernest Choy

Fantastic. So, I mean, you mentioned about multi-disciplinary involvement, I guess one of the key stakeholders with this guidelines are the other podiatrists. Lara, as a podiatrist, could you explain how this guideline can be used by those in your profession? 

Lara Chapman:

Yeah. I mean, I think certainly in podiatry, there's, there's a lot of variation in terms of how patients with foot problems in inflammatory arthritis are assessed and managed. So having an up to date guideline that's based on the best available evidence should improve the quality and consistency of care. It provides guidance about specific issues that are often faced by podiatrists, so, for example, ulcers and toenail infections, footwear and orthoses. So I think it will give podiatrists more confidence when treating these patients and making clinical decisions. And then we've also developed an audit tool that can be modified locally to help with implementing the guideline. So this will allow podiatrists and other health professionals as well to assess how their practice adheres to the guideline and to see where improvements are needed. 

Ernest Choy  10:00

I mean another key healthcare professionals that are involved in the development of guideline are physiotherapists. So, I'll open this question to any of you who want to comment, how may physiotherapists contribute to the management of individuals who have foot problems and inflammatory arthritis? 

Edward Roddy:

So I think one of the things that your question highlights, Ernest, is how little evidence we were able to find about issues such as exercises and physical activity relating to the foot in people with inflammatory arthritis. So we certainly need more evidence in this area, and I guess that those are issues that we, as healthcare professionals, and also our patients, look to our physiotherapy colleagues to advise, and we certainly need the evidence to try and support them in their practice. 

Ernest Choy:

And to continue on the same lines, as someone from the Centre for Primary Care at Keele, Ed, how do you think this guideline will support the management of these individuals in primary care? 

Edward Roddy:

Well, that's a really important question Ernest and, of course, really important for implementation, and it's not an easy question for a secondary care rheumatologist to answer. So, our guideline working group did include a GP, so I asked them what they thought about this important issue in preparation for answering this question. And I think one of the most important things it will hopefully do is to raise the profile and awareness of foot problems in inflammatory arthritis, how common they are, the burden they pose to patients and the related unmet need. And, quite simply, as Lara said earlier, the need to ask about foot problems when they're seeing people with inflammatory arthritis. 

There are a number of other specific areas where I think the guideline can offer particularly specific advice which might be relevant to primary care. One of these is when to seek help from specialist foot care professionals and who to seek help from. And then also specifically about drugs, about DMARDs and biologics, and offering advice for those key times when people might be uncertain, such as the time of surgery, and if concerned about infection in the foot. 

Ernest Choy:

Great. So we've heard that foot problems are common in patients with inflammatory arthritis. It affects the quality of life throughout all ages, both children and adults, and it is important to have multidisciplinary care for these individuals. So, hopefully, this guideline will help healthcare professionals to examine the organisation of care locally. 

Are there any additional resources that may help people to look at their practice and whether they meet the standard recommended in the guidelines? 

Gavin Cleary:

If I may come in with the voice of children and young people. I guess much of paediatric rheumatology care is focused around sort of hub specialty children's hospitals with different provisions of network care nationally. So I would really just sort of make the point that the recommendations in the guideline really should be available to all on an equitable basis. So I would hope that the guideline could be, you know, perhaps helpful if there are service provisions across networks to help support development of equitable care for all. 

Edward Roddy:

I would reinforce the point that Lara made about the audit tool, because that, like lots of BSR guidelines, will be published as an appendix to the guideline, and it's there, it's available for people to use and ready to see where the gaps in their care are. 

Ernest Choy:

I want to thank all of you for joining me today. I hope those who are listening will find this helpful. The guideline is available at the BSR website, together with the audit tool that has been mentioned. I hope this gives an opportunity for local rheumatology teams to examine their own practice, and, hopefully, by auditing and improving their practice, will improve the life of people with inflammatory arthritis who have experienced foot problems, both children and adults. Thank you very much.

Narrator:

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