Andrea Graham

‘My feet – visible, but ignored . . .’ A qualitative study of foot care for people with rheumatoid arthritis

Objective: To explore patients’ experiences of foot problems associated with rheumatoid arthritis, from onset of symptoms to being provided with foot health interventions. Design: A qualitative design was used with an interpretive phenomenological approach to the data collection and analysis. Setting: University of Salford, School of Health Science. Subjects: Sixteen female and six male adults with rheumatoid arthritis-related foot problems and experience of receiving foot health interventions. Method: Data were collected through digital recordings of three focus groups which were conducted by an experienced researcher. An observer made field notes. Transcribed data were analysed using a thematic framework. Data were verified with randomly selected participants and agreement achieved with the participants, researcher and observer. Results: The results were organized into five themes: the significance of foot symptoms in relation to diagnosis of rheumatoid arthritis; knowledge of and explanation about foot symptoms; accessing foot health interventions; the effectiveness of foot health interventions; and improvements to foot health interventions. Despite foot problems being of concern to the participants, they were often ignored by practitioners from before diagnosis through to foot management. Conclusions: This study has highlighted a polarity between what these participants need in relation to their foot symptoms and the management of them. That foot problems are often ignored is of concern at multiple levels. These range from the implications of ignoring foot symptoms that may aid diagnosis of rheumatoid arthritis, to ignoring the need for effective foot health interventions.

The rheumatoid foot: a systematic literature review of patient-reported outcome measures

BackgroundThe foot is often the first area of the body to be systematically affected by rheumatoid arthritis. The multidimensional consequences of foot problems for patients can be subjectively evaluated using patient-reported outcome measures (PROMs). However, there is currently no systematic review which has focused specifically upon the PROMs available for the foot with rheumatoid arthritis. The aim of this systematic review was to appraise the foot-specific PROMs available for the assessment and/or evaluation of the foot affected with rheumatoid arthritis.MethodsA systematic search of databases was conducted according to pre-defined inclusion/exclusion criteria. PROMs identified were reviewed in terms of: conceptual bases, quality of construction, measurement aims and evidence to support their measurement properties.ResultsA total of 11 PROMs were identified and 5 papers that provided evidence for the measurement properties of some of the PROMs. Only one of the PROMs was found to be RA disease-specific. The quality of construction, pretesting and presence of evidence for their measurement properties was found to be highly variable. Conceptual bases of many of the PROMs was either restricted or based on reductionist biomedical models. All of the PROMs were found to consist of fixed scales.ConclusionsThere is a need to develop an RA-disease and foot-specific PROM with a greater emphasis on a biopsychosocial conceptual basis, cognitive pre-testing methods, patient preference-based qualities and evidence to support the full complement of measurement properties.

Guidelines for the management of people with foot health problems related to rheumatoid arthritis: a survey of their use in podiatry practice

BackgroundIn the last decade there has been a significant expansion in the body of knowledge on the effects of rheumatoid arthritis (RA) on the foot and the management of these problems. Aligned with this has been the development of specialist clinical roles for podiatrists. However, despite being recommended by national guidelines, specialist podiatrists are scarce. In order to inform non-specialist podiatrists of the appropriate interventions for these foot problems, management guidelines have been developed and disseminated by a group of specialist podiatrists. The aim of this survey was to investigate the use of these guidelines in clinical practice.MethodFollowing ethical approval an online questionnaire survey was carried out. The questions were formulated from a focus group and comprised fixed response and open response questions. The survey underwent cognitive testing with two podiatrists before being finalised. An inductive approach using thematic analysis was used with the qualitative data.Results245 questionnaires were completed (128–non-specialist working in the private sector, 101 non–specialists working in the NHS and 16 specialist podiatrists). Overall, 97% of the non-specialists (n = 222) had not heard of the guidelines. The non-specialists identified other influences on their management of people with RA, such as their undergraduate training and professional body branch meetings. Three main themes emerged from the qualitative data: (i) the benefits of the foot health management guidelines, (ii) the barriers to the use of guidelines generally and (iii) the features of useable clinical guidelines.ConclusionsThis study has revealed some crucial information about podiatrists’ level of engagement with the foot health management guidelines and the use of guidelines in general. Specifically, the non-specialist podiatrists were less likely to use the foot health management guidelines than the specialist podiatrists. The positive aspects were that for the specialist practitioners, the guidelines helped them to identify their professional development needs and for the few non-specialists that did use them, they enabled appropriate referral to the rheumatology team for foot health management. The barriers to their use included a lack of understanding of the risk associated with managing people with RA and that guidelines can be too long and detailed for use in clinical practice. Suggestions are made for improving the implementation of foot health guidelines.

Foot health education for people with rheumatoid arthritis - some patient perspectives.

BackgroundPatient education is an important component of foot health management for people with rheumatoid arthritis (RA). The content and strategies for delivery require investigation in relation to the patients’ needs. This study explores patients’ experiences of foot health education, to inform how the patients’ needs could be identified in clinical practice and inform effective education delivery.MethodA focus group was used to collect data. The dialogue was recorded digitally, transcribed verbatim and analysed using a structured thematic approach. Member checking and peer review added to credibility of the data.Six themes emerged; (i) content and purpose of patient education – what it should be, (ii) content of patient education – what it should not be, (iii) timing of information on foot health, (iv) method of delivery, (v) ability to engage with foot health education and (vi) the patient/practitioner relationship.ConclusionsThis study identified aspects of patient education considered important by this group of patients in relation to content, timing and delivery, forming the basis for further research on clinical and patient focussed outcomes of patient education.Identifying health education needs and provision of supportive verbal and written information can foster an effective therapeutic relationship, supporting effective foot health education for people with RA.

Therapeutic Foot Health Education for Patients with Rheumatoid Arthritis: A Narrative Review

PURPOSE Foot health interventions such as foot orthoses for people with rheumatoid arthritis (RA) reduce pain, improve function and improve overall quality of life. Additionally, patient education (PE) is considered essential in achieving good outcomes with interventions such as foot orthoses, footwear and self-care. The aim of this literature review was to identify evidence in relation to the content, use and delivery of PE in the management of RA foot problems. METHODS An electronic search of the following databases was performed: PubMed, CINAHL, AMED, Medline and the Cochrane Library, between March 2000 and March 2010. In order to be included, studies had to be published in English, involve adults (>18 years) with RA, and assist in answering the research question. No publications regarding PE for the management of foot health-related problems in RA were found. However, other key terms emerged that embraced PE for people with RA and informed a further search. Thirty-two papers met the inclusion criteria and were reviewed with regard to the subject area, content of the paper, methodological issues and their key findings. RESULTS The present review provides evidence for the effectiveness of PE for people with RA delivered via a staged approach, with the content and timing of education provision being driven by the needs of the patient. CONCLUSIONS The effect of PE delivered from a podiatric context needs to be explored, and the nature and requirements of PE for individuals with RA-related foot problems from a patient and practitioner perspective requires investigation. Alternative and innovative ways of providing PE and, potentially, self-management need to be investigated and defined.

A survey of people with foot problems related to rheumatoid arthritis and their educational needs

BackgroundUp to 50% of people with rheumatoid arthritis (RA) have foot symptoms at diagnosis, hence early foot health intervention is recommended and this should include patient education. This study identifies, for the first time, the foot health education (FHE) needs of people with RA.MethodsAn online survey of people with RA (n = 543) captured quantitative data in relation to the aims, methods of delivery, content, timing and accessibility of FHE.ResultsThe majority concurred about the aims of FHE. Verbal delivery and websites were the most common methods. Written and verbal FHE were perceived to be the most effective methods. The point of diagnosis was the preferred time to receive it. Lack of access to FHE included minimal focus on foot health during consultations by both health practitioners and patients with RA. Participant gender, age, disease duration and living situation had a statistically significant influence on the results.ConclusionFoot health education is rarely considered within the medical consultation. There is a lack of patient and/or health professional awareness of this need with a detrimental impact on foot health. Patients require health professionals to identify their foot education health needs. Tailored foot health education should begin at initial diagnosis.

Foot health education provision for people with rheumatoid arthritis–an online survey of UK podiatrists’ perceptions

BackgroundPatient education supports general disease self-management and in relation to foot problems, it is recommended as a key intervention for people with rheumatoid arthritis (RA). Further, it is known what the foot health educational (FHE) needs are in relation to their experiences of foot problems. Podiatrists are the key health professionals who provide the management of RA-related foot pathology and this includes the delivery of FHE. However, we do not know what is currently provided and what podiatrists’ perceptions are of this intervention. It is possible that there is a difference between what is provided and what patients need in order to maximise their foot health benefits and hence this may contribute to the persistence of foot problems and symptoms. This study primarily aims to define what UK podiatrists’ perceptions of FHE are in relation to; what is delivered, how it is delivered, and the timing of its delivery, in the context of its’ accessibility. The secondary aim is to identify any influence of the participants’ gender, age and duration of professional qualification on their responses.MethodAn online survey of UK HCPC registered podiatrists was used to capture quantitative data in relation to the perceived; aims, content, methods and effectiveness, timing and barriers to FHE provision to people with RA. Data was analysed to assess significant associations between the participant responses and their gender, age and duration of professional qualification. Free text comments were analysed using thematic analysis.Results43 podiatrists across the UK completed the survey. The majority of participants stated that, they provided FHE and agreed with its overall aims. The most common methods of delivery that were perceived to be most effective were: verbal, written and website based information. The best times at which to deliver FHE were thought to be at the point of diagnosis of RA and at any available opportunity of health care delivery. The majority of participants thought they had enough knowledge and access to information resources to effectively deliver FHE, but half of the participants felt that consultation duration limited their ability to do so. Gender and duration of professional qualification influenced participants’ perceptions of FHE.ConclusionThe importance and content of FHE for people with RA has been defined, but time limitations are seen to restrict its delivery. The development of an education needs analysis tool to facilitate efficient identification of patients FHE needs could enable timely and tailored delivery of FHE to people with RA.

Development of a patient-reported outcome measure for the foot affected by rheumatoid arthritis.

OBJECTIVE To develop an idiographic and nomothetic patient-reported outcome measure (PROM) for the assessment and evaluation of patients with feet affected by rheumatoid arthritis (RA). STUDY DESIGN AND SETTING The development of the Salford Rheumatoid Arthritis Foot Evaluation (SAFE) Instrument PROM was divided into four stages: establishment of the PROMs conceptual basis and content generation, following a descriptive phenomenological study; clinimetric instrument development; instrument pretesting, involving expert reviews and cognitive interviews; and demonstration of instrument measurement properties, including convergent validity and test-retest reliability of the nomothetic scale. RESULTS A total of 123 items were initially generated for the SAFE, with 25 of them clinimetrically selected for nomothetic scale (SAFE-Part A) and 80 items initially included in the idiographic scale (SAFE-Part B). The pretesting strategy proved effective for improving and refining the SAFE, with the final draft consisting of 19 items in Part A and 42 items in Part B. The SAFE-Part A has strong evidence for convergent validity and test-retest reliability. CONCLUSION The SAFE features a nomothetic and idiographic assessment strategy that, with further development, will prove to be a valuable tool for clinicians involved in managing the foot health problems associated with RA.

Development of the Salford Rheumatoid Arthritis Foot Evaluation Instrument (SAFE)

Background For clinicians involved in managing the foot with rheumatoid arthritis (RA), there is a dearth of patientreported outcome measures (PROs) available with only the Leeds Foot Impact Scale (LFIS). The LFIS currently lacks evidence for important measurement properties, does not permit a patient-specific assessment strategy and was designed using a restrictive scaling strategy. Therefore, the aim of this research was to develop a new PRO, the Salford Rheumatoid Arthritis Foot Evaluation Instrument (SAFE), working closely with clinicians and patients, to create an instrument with multiple assessment strategies (fixed and patient-specific) and rigorous measurement properties.