Lindsey Hooper

Prognostic indicators of foot-related disability in patients with rheumatoid arthritis: results of a prospective three-year study.

To determine the prevalence and natural history of foot‐related disability in patients with rheumatoid arthritis (RA). A secondary aim was to identify explanatory variables, including forefoot bursae, that are either associated with or predictive of disabling foot complications in patients with RA.

Assessment of the natural history of forefoot bursae using ultrasonography in patients with rheumatoid arthritis: a twelve-month investigation.

To determine the natural history and clinical significance of forefoot bursae over a 12‐month period in patients with rheumatoid arthritis (RA).

Forefoot pathology in rheumatoid arthritis identified with ultrasound may not localise to areas of highest pressure: cohort observations at baseline and twelve months

BackgroundPlantar pressures are commonly used as clinical measures, especially to determine optimum foot orthotic design. In rheumatoid arthritis (RA) high plantar foot pressures have been linked to metatarsophalangeal (MTP) joint radiological erosion scores. However, the sensitivity of foot pressure measurement to soft tissue pathology within the foot is unknown. The aim of this study was to observe plantar foot pressures and forefoot soft tissue pathology in patients who have RA.MethodsA total of 114 patients with established RA (1987 ACR criteria) and 50 healthy volunteers were assessed at baseline. All RA participants returned for reassessment at twelve months. Interface foot-shoe plantar pressures were recorded using an F-Scan® system. The presence of forefoot soft tissue pathology was assessed using a DIASUS musculoskeletal ultrasound (US) system. Chi-square analyses and independent t-tests were used to determine statistical differences between baseline and twelve months. Pearsons correlation coefficient was used to determine interrelationships between soft tissue pathology and foot pressures.ResultsAt baseline, RA patients had a significantly higher peak foot pressures compared to healthy participants and peak pressures were located in the medial aspect of the forefoot in both groups. In contrast, RA participants had US detectable soft tissue pathology in the lateral aspect of the forefoot. Analysis of person specific data suggests that there are considerable variations over time with more than half the RA cohort having unstable presence of US detectable forefoot soft tissue pathology. Findings also indicated that, over time, changes in US detectable soft tissue pathology are out of phase with changes in foot-shoe interface pressures both temporally and spatially.ConclusionsWe found that US detectable forefoot soft tissue pathology may be unrelated to peak forefoot pressures and suggest that patients with RA may biomechanically adapt to soft tissue forefoot pathology. In addition, we have observed that, in patients with RA, interface foot-shoe pressures and the presence of US detectable forefoot pathology may vary substantially over time. This has implications for clinical strategies that aim to offload peak plantar pressures.

Improvement in symptoms and signs in the forefoot of patients with rheumatoid arthritis treated with anti-TNF therapy

BackgroundInhibition of tumour necrosis factor (TNF) is an effective way of reducing synovitis and preventing joint damage in rheumatoid arthritis (RA), yet very little is known about its specific effect on foot pain and disability. The aim of this study was to evaluate whether anti-TNF therapy alters the presence of forefoot pathology and/or reduces foot pain and disability.MethodsConsecutive RA patients starting anti-TNF therapy (infliximab, etanercept, adalimumab) were assessed for presence of synovial hypertrophy and synovitis in the 2nd and 5th metatarso-phalangeal (MTP) joints and plantar forefoot bursal hypertrophy before and 12 weeks after therapy. Tender MTP joints and swollen bursae were established clinically by an experienced podiatrist and ultrasound (US) images were acquired and interpreted by a radiologist. Assessment of patient reported disease impact on the foot was performed using the Manchester Foot Pain and Disability Index (MFPDI).Results31 patients (24 female, 7 male) with RA (12 seronegative, 19 seropositive) completed the study: mean age 59.6 (SD 10.1) years, disease duration 11.1 (SD 10.5) years, and previous number of Disease Modifying Anti Rheumatic Drugs 3.0 (1.6). Significant differences after therapy were found for Erythrocyte Sedimentation Rate (t = 4.014, p < 0.001), C-reactive protein (t = 3.889, p = 0.001), 28 joint Disease Activity Score (t = 3.712, p = 0.0001), Visual Analog Scale (t = 2.735, p = 0.011) and Manchester Foot Pain and Disability Index (t = 3.712, p = 0.001).Presence of MTP joint synovial hypertrophy on US was noted in 67.5% of joints at baseline and 54.8% of joints at twelve weeks. Presence of plantar forefoot bursal hypertrophy on US was noted in 83.3% of feet at baseline and 75% at twelve weeks. Although there was a trend for reduction in observed presence of person specific forefoot pathology, when the frequencies were analysed (McNemar) this was not significant.ConclusionsSignificant improvements were seen in patient reported foot pain and disability 12 weeks after commencing TNF inhibition in RA, but this may not be enough time to detect changes in forefoot pathology.

Comparative distribution of ultrasound-detectable forefoot bursae in patients with osteoarthritis and rheumatoid arthritis

To investigate the prevalence and distribution of forefoot bursae (FFB) in individuals with osteoarthritis (OA), individuals with rheumatoid arthritis (RA), and healthy controls (HCs), and to identify mechanical or inflammatory factors predicting FFB count.

Within-subject foot motion variability in patients with Rheumatoid Arthritis

Multi-segment three-dimensional analysis is a complex yet rapidly evolving methodology in podiatric mechanical research. The purpose of this study was to explore the within-subject foot motion variability (MoVa) during the stance phase of gait.

A CONTROLLED STUDY OF PLANTAR FOOT PRESSURES IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background: inflamed bursae (bursitis) within the forefoot are highly prevalent in rheumatoid arthritis (RA), under diagnosed and impact heavily on patients’ pain, mobility and quality of life. In order to optimise the management of these patients it is essential to describe the natural history and progression of these structures over time. The objectives were to investigate whether forefoot bursitis changes over a one year period and if it does change to explore what predicts that change. Methods: a cohort study design was used in which a sample of RA patients (N¼120 from an original baseline of N¼149) who had already been assessed at baseline were reassessed one year following their initial visit. A Diasus ultrasound system was used to image the forefeet of all participants to determine the presence and total occurrences of plantar forefoot bursitis. Foot pain was determined by both subscales of the Leeds Foot Impact Scale (LFIS), impairment/footwear (LFISIF) and activity participation limitation (LFISAP). Results: 120 patients (98 female and 22 male) with RA (24 seronegative and 93 seropositive, 3 data missing) completed the study: mean age 60.7 (SD12.1) years, weight 72.6 (15.3) Kg, disease duration 12.99 (10.4) years. 78 (65%) were taking methotrexate and 55 (45.7%) anti-TNF therapy. Baseline and one year follow up data for clinical variables are shown in Table 1. On examination of person specific data when grouped according to occurrences of MSUS bursitis (group1: 0–2; group2: 3–6; group3: 7–11) 31 participants had an increase, 28 decrease and 61 had the same number of MSUS bursitis after one year. There was a significant positive correlation between the changes in MSUS bursitis with changes in both LFISIF (PCC¼0.216, p¼0.018) and LFISAP (PCC¼0.193, p¼0.036) and a significant negative correlation with changes in duration of RA (PCC¼0.269, p¼0.003). Conclusions: the study findings imply that bursitis in the forefeet does change over time and remains as an important factor related to RA patients’ foot pain and disability with increases in bursitis in the forefeet being related to increases in foot pain and disability. Furthermore bursitis in the forefeet of RA patients with longer disease duration decreased after one year whilst those with early disease tended to have more variance in the changes of bursitis. This suggests that regular foot imaging assessments particularly for RA patients with early disease would be beneficial. Disclosures: the authors have declared no conflicts of interestBackground: foot pressures are elevated within the RA foot, particularly under the forefoot. Recent evidence has linked joint damage, as measured by radiological erosion scores, to increased plantar forefoot pressures. However, it is not clear whether plantar forefoot pressures in RA are also related to inflammatory disease activity. The objective of this study was to investigate relationships between forefoot pressures and disease activity (DAS28) in a sample of RA patients. Methods: a cross sectional study design was used in which patients with RA (ACR criteria) were investigated for plantar foot pressures. Foot pressure measurements were recorded by an FScan In-shoe system, (Tekscan Inc. USA) according to standard protocol. Average foot pressures were calculated for the entire plantar foot area, and the third step was selected for analysis. The outcome variables (identified in Table 1) for both left and right feet were recorded. The data was split into groups according to DAS28 scores(identified in table 1) to define RA disease activity. Results: 149 patients (119 female and 30 male) with RA (34 seronegative, 114 seropositive and 1 unidentified) completed the study: mean age 59.3 (SD 12.5) years, weight 73.3 (14.9) Kg, disease duration 12.28 (10.3) years. The mean ESR was 23.3 (19.2), CRP 12.5 (18.1), DAS28 scores 3.9 (1.3). Foot pressure and footstep time variables are reported in table 1. Using analysis of variance no significant differences between DAS28 groups were found for any of the foot pressure variables (Peak pressure L p¼0.410, R p¼0.412; Time of peak pressure L p¼0.094, R p¼0.075; Total footstep time L p¼0.165, R p¼0.459; Force-time integral L p¼0.441, R p¼0.961; Mean force L p¼0.867, R p¼0.452). However, a test for trend showed there was a borderline association between DAS28 group and time of peak pressure (left p¼0.014; right p¼0.058) and that this was independent of age (left ¼0.063 p¼0.01;, right ¼0.043, p¼0.058). Conclusions: data from this study suggest that patients with higher disease activity may have longer times of peak pressures. Since longer times of peak pressures in diabetes patients have been linked to secondary mechanical damage, it is recommended that further investigations into the importance of temporal and spatial foot pressures in RA patients with high disease activity is undertaken. Disclosures: A.G. received funding from Arthritis Research Campaign for a research intern for the duration of the study. C.B., L.H., C.J.E., D.C. and N.K.A. have declared no conflicts of interest

PLANTAR FOOT PRESSURES ARE NOT RELATED TO DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS

Background: inflamed bursae (bursitis) within the forefoot are highly prevalent in rheumatoid arthritis (RA), under diagnosed and impact heavily on patients’ pain, mobility and quality of life. In order to optimise the management of these patients it is essential to describe the natural history and progression of these structures over time. The objectives were to investigate whether forefoot bursitis changes over a one year period and if it does change to explore what predicts that change. Methods: a cohort study design was used in which a sample of RA patients (N¼120 from an original baseline of N¼149) who had already been assessed at baseline were reassessed one year following their initial visit. A Diasus ultrasound system was used to image the forefeet of all participants to determine the presence and total occurrences of plantar forefoot bursitis. Foot pain was determined by both subscales of the Leeds Foot Impact Scale (LFIS), impairment/footwear (LFISIF) and activity participation limitation (LFISAP). Results: 120 patients (98 female and 22 male) with RA (24 seronegative and 93 seropositive, 3 data missing) completed the study: mean age 60.7 (SD12.1) years, weight 72.6 (15.3) Kg, disease duration 12.99 (10.4) years. 78 (65%) were taking methotrexate and 55 (45.7%) anti-TNF therapy. Baseline and one year follow up data for clinical variables are shown in Table 1. On examination of person specific data when grouped according to occurrences of MSUS bursitis (group1: 0–2; group2: 3–6; group3: 7–11) 31 participants had an increase, 28 decrease and 61 had the same number of MSUS bursitis after one year. There was a significant positive correlation between the changes in MSUS bursitis with changes in both LFISIF (PCC¼0.216, p¼0.018) and LFISAP (PCC¼0.193, p¼0.036) and a significant negative correlation with changes in duration of RA (PCC¼0.269, p¼0.003). Conclusions: the study findings imply that bursitis in the forefeet does change over time and remains as an important factor related to RA patients’ foot pain and disability with increases in bursitis in the forefeet being related to increases in foot pain and disability. Furthermore bursitis in the forefeet of RA patients with longer disease duration decreased after one year whilst those with early disease tended to have more variance in the changes of bursitis. This suggests that regular foot imaging assessments particularly for RA patients with early disease would be beneficial. Disclosures: the authors have declared no conflicts of interestBackground: foot pressures are elevated within the RA foot, particularly under the forefoot. Recent evidence has linked joint damage, as measured by radiological erosion scores, to increased plantar forefoot pressures. However, it is not clear whether plantar forefoot pressures in RA are also related to inflammatory disease activity. The objective of this study was to investigate relationships between forefoot pressures and disease activity (DAS28) in a sample of RA patients. Methods: a cross sectional study design was used in which patients with RA (ACR criteria) were investigated for plantar foot pressures. Foot pressure measurements were recorded by an FScan In-shoe system, (Tekscan Inc. USA) according to standard protocol. Average foot pressures were calculated for the entire plantar foot area, and the third step was selected for analysis. The outcome variables (identified in Table 1) for both left and right feet were recorded. The data was split into groups according to DAS28 scores(identified in table 1) to define RA disease activity. Results: 149 patients (119 female and 30 male) with RA (34 seronegative, 114 seropositive and 1 unidentified) completed the study: mean age 59.3 (SD 12.5) years, weight 73.3 (14.9) Kg, disease duration 12.28 (10.3) years. The mean ESR was 23.3 (19.2), CRP 12.5 (18.1), DAS28 scores 3.9 (1.3). Foot pressure and footstep time variables are reported in table 1. Using analysis of variance no significant differences between DAS28 groups were found for any of the foot pressure variables (Peak pressure L p¼0.410, R p¼0.412; Time of peak pressure L p¼0.094, R p¼0.075; Total footstep time L p¼0.165, R p¼0.459; Force-time integral L p¼0.441, R p¼0.961; Mean force L p¼0.867, R p¼0.452). However, a test for trend showed there was a borderline association between DAS28 group and time of peak pressure (left p¼0.014; right p¼0.058) and that this was independent of age (left ¼0.063 p¼0.01;, right ¼0.043, p¼0.058). Conclusions: data from this study suggest that patients with higher disease activity may have longer times of peak pressures. Since longer times of peak pressures in diabetes patients have been linked to secondary mechanical damage, it is recommended that further investigations into the importance of temporal and spatial foot pressures in RA patients with high disease activity is undertaken. Disclosures: A.G. received funding from Arthritis Research Campaign for a research intern for the duration of the study. C.B., L.H., C.J.E., D.C. and N.K.A. have declared no conflicts of interest