October 2012

Juvenile idiopathic arthritis study reveals footcare information gap

Photo by Vincent Giordano/Trinacria Photography (www.trinacriaphotography.com), courtesy of Clinical Prosthetics & Orthotics.

Issues involve custom foot orthoses

By Larry Hand

A Scottish study suggests foot care in children with juvenile idiopathic arthritis (JIA) falls short because of poor access to care and negative perceptions about custom foot orthoses. Experts say those issues may be less prevalent in the US but emphasize the need to educate patients, parents, and referring clinicians about the benefits of lower extremity care.

The study, published online in July in the Archives of Physical Medicine and Rehabilitation, identified six key themes that emerged from conversations with four teenaged patients, two parents, three pediatric rheumatologists, and six other healthcare professionals. The participants were from two National Health Service rheumatology centers in Glasgow, UK.

Patients identified pain as the main impact of the disease, and cited physical activity and footwear problems as causes of pain. However, patients said they were “prepared to endure high levels of pain and stiffness” if they could maintain mobility, which was the main impact of disease cited by healthcare professionals and parents. Patients also perceived that pain and mobility impairment interfered with their abilities to perform everyday tasks or participate in sports, which also resulted in feelings of distress, depression, and isolation.

Patients and parents all reported problems finding appropriate and comfortable shoes. All participants complained about lack of access to lower extremity specialists. The healthcare professionals expressed reluctance to refer because they perceived a lack of evidence supporting the effectiveness and cost efficiency of foot orthoses for JIA patients. While some considered the devices beneficial for easing pain, others considered foot orthoses “as a waste of time and money due to noncompliance.”

“Finding solutions for footwear difficulties experienced in this patient group is challenging,” said lead author Gordon J. Hendry, PhD, formerly of Glasgow Caledonian University and now a lecturer in podiatric medicine at the University of Western Sydney in Australia. “Further research is required to determine what aspects of footwear are important to parents, as well as young and adolescent boys and girls.”

Further research is needed on how, specifically, foot orthoses affect foot mechanics and inflamed joints and soft tis-­ sues, and if the benefits of custom foot orthoses justify the costs, Hendry said.

“The current evidence suggests that customized foot orthoses are reasonably effective in reducing foot pain in inflammatory arthritis conditions,” he said. “There is as yet no significant evidence that foot orthoses halt the destructive inflammatory processes associated with conditions such as rheumatoid arthritis and JIA. This question needs to be addressed through clinical trials using sensitive imaging techniques.”

The study’s findings related to access to care likely are not what one would find in the US, said Russell Volpe, DPM, professor of orthopedics and pediatrics at the New York College of Podiatric Medicine in New York City.

Noting that the effectiveness of foot orthoses for pain reduction in juvenile arthritis was documented in a 2005 randomized study by Powell et al published in the Journal of Rheumatology, Volpe suggested that the effects on pain alone should be enough to justify the use of foot orthoses.

“The already documented ability of FOs to reduce pain in juvenile arthritis patients should be enough to see that these children get into appropriate FOs,” Volpe said.

The 2005 study found that 15 children with JIA wearing custom semirigid foot orthoses with shock-absorbing posts experienced significantly greater improvement in pain and function at three months than children who only used supportive athletic shoes or off-the-shelf shoe inserts. The authors argued that the cost of the custom orthoses ($250—$350 per pair) over time would be less than other medical interventions.

However, the study authors also wrote that, because materials and methods used in fabricating custom orthotics vary, “the needs of the patient, whether accommodative, biomechanical, or functional, influence the choice of orthotic.”

If the patients in this recent study had better access to lower extremity care, Volpe said, many more of them would have been able to benefit from the pain-reducing effects of foot orthoses.

“In the face of the Powell study, that some of the clinicians thought FOs were a ‘waste of time’ betrays a sad ignorance on their part,” he said.

Larry Hand is a writer based in Massachusetts.

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Hendry GJ, Turner DE, Lorgelly PK, Woodburn J. Room for improvement: patient, parent, and practitioners’ perceptions of foot problems and foot care in juvenile idiopathic arthritis. Arch Phys Med Rehabil 2012 Jul 25 [Epub ahead of print]

Powell M, Seid M, IS. Efficacy of custom foot orthotics in improving pain and functional status in children with juvenile idiopathic arthritis: a randomized trial. J Rheumatol 2005;32(5):943-950.

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