Footwear and orthosis provision: the evidence in musculoskeletal disease

1. Footwear and orthosis provision: the evidence in musculoskeletal disease Professor Anthony Redmond  Arthritis Research UK Senior Lecturer, Foot and Ankle STudiEs in Rheumatology (FASTER) Program Leeds Institute of Molecular Medicine, University of Leeds. Professor of Clinical Biomechanics, Staffordshire University.

2. Orthoses ISO definition: �any externally applied device used to modify the structural and functional characteristics of the neuromuscular and musculoskeletal system� (ISO 8549-1). Foot orthoses worn inside footwear such as: simple cushioning insoles arch supports and other padded insoles to which modular additions can be made contoured insoles intended to change the function of leg and foot joints 3a. Custom made to a cast of the patient�s foot 3b. Supplied off the shelf customised accommodative orthoses (sometimes called total contact insoles)

3. Footwear standard retail footwear niche retail including comfort footwear as well as extra depth, extra width and odd-size suppliers. specialist therapeutic footwear standard or �stock� footwear modular footwear based on a stock base and customisable to individual needs made to measure or bespoke footwear.

4. Advice for the footwear at the right times. Be inventive Stock footwear over taken bespoke Running footwear equal to orthopaedic in pressure reduction and preference preliminary study (Hennessy et al. 2007) Advice for the footwear at the right times. Be inventive Stock footwear over taken bespoke Running footwear equal to orthopaedic in pressure reduction and preference preliminary study (Hennessy et al. 2007)

5. Evidence for effectiveness

6. Orthoses 1. simple cushioning insoles (Jackson 2004) 2. arch supports and other padded insoles to which modular additions can be made (Kavlak et al 2003) 3. contoured insoles intended to change the function of leg and foot joints (Woodburn 2003, Redmond 2009) 3a. Custom made to a cast of the patient�s foot 3b. Supplied off the shelf 4. customised accommodative orthoses (sometimes called total contact insoles) (Hodge 1999) Cochrane review (Egan 2003), SRs (Farrow 2008)

7. Simple insoles 12% decrease in forefoot pressure 21% with additional bar (Jackson 2004)

9. Functional Foot Orthoses Plausible mechanisms of action Motion Control / limit excessive abnormal motion in foot joints Protect joints / rest tissues Improve / maintain function at joints Improve walking parameters Pressure/force Decrease plantar forces (cushioning) Redistribute pressure or off-load painful areas / ulcer sites Accommodate foot deformity

10. Functional orthoses In early RA Reduction in pain Potential for minimising future joint damage Long-term benefits associated with early orthotic therapy in RA  Baseline evaluation � LFIS, radiography, FPI/Platto Minimising future joint damage � Rigid orthoses Off loading strategies, particularly in the forefoot � reduce pain minimise gait changes Long-term benefits associated with early orthotic therapy in RA (Woodburn, J., Helliwell & Barker 2003). Baseline evaluation � LFIS, radiography, FPI/Platto Minimising future joint damage � Rigid orthoses Off loading strategies, particularly in the forefoot � reduce pain minimise gait changes Long-term benefits associated with early orthotic therapy in RA (Woodburn, J., Helliwell & Barker 2003).

12. Functional orthoses Plantar fasciitis Short term benefits 7-8% improvement in pain compared to sham No longer term benefits Similar for customised and prefabricated designs (Landorf et al 2006)

13. Off the shelf vs custom Off loading strategies, particularly in the forefoot (Redmond 2000, Hodge, Bach & Carter 1999; Woodburn, J., Barker & Helliwell 2002; Woodburn, J., Helliwell & Barker 2003). Work needed re economic case (Redmond 2009) 

17. Positive reinforcement!

18. Accommodative orthoses Managing the changing foot, secondary features  Proactive, preventative Tx ? reactive, accommodative or palliative interventions. Functional intervention = mix of control and support. Flexible orthoses, �total contact� type reduce pressure by ~20% Reduce pain by 50% (Hodge, Bach & Carter 1999).   

19. Footwear Large but patchy body of evidence Good evidence in diabetes Weaker in musculoskeletal disease

20. Footwear in RA Extra depth footwear (Fransen 1997) Improvement over regular footwear in : HAQ Pain on walking (18%)

21. Orthopaedic footwear Traditional design vs new design (Williams et al 2007) Improved foot pain and function with new design No improvement in controls Highlighted significant compliance problems Only 9/40 patients in control arm completed study

22. NICE CG 79 for RA Recommendation 15�� Functional insoles and therapeutic footwear should be available for all people with RA if indicated.

23. Clark H, Rome K, Plant M, O�Hare K and Gray J (2006), �A critical review of foot orthoses on the rheumatoid arthritic foot�, Rheumatology, 2006; 45: 139-145 Burns SL, Leese GP, McMurdo MET. Older people and ill fitting shoes. PG Med J 2002;78:344-346. Williams A, Meacher K. Shoes in the cupboard: the fate of prescribed footwear? Prost and Orthot 2001;25:53-59. Hodge MC, Bach TM, Carter GM. orthotic management of plantar pressure and pain in rheumatoid arthritis. Clin Biomech 1999;14(8):567-575. Kavlak Y, Uygur F, Korkmaz C, Bek N. Outcomes of orthoses intervention in the rheumatoid foot. Foot and Ankle Intl 2003;24(6):494-499 Woodburn J, Helliwell PS, Barker S. Changes in 3D joints kinematics support the continuous use of orthoses in the management of painful rearfoot deformity in rheumatoid arthritis. J of Rheuma 2003;30(11):2356-64. Egan, M., et al., Splints/orthoses in the treatment of rheumatoid arthritis. Cochrane Database of Systematic Reviews., 2003(1): p. CD004018. Williams, A.E., K. Rome, and C.J. Nester, A clinical trial of specialist footwear for patients with rheumatoid arthritis. Rheumatology, 2007. 46(2): p. 302-307.

24. Design �If I didn�t have RA I wouldn�t give them house room.� (Goodacre 2011) Changing feet Fit and choice All part of the outfit

25. Numbers Almost all people with RA have foot involvement 9% of all over 55s Audit commission estimate in 2000 =400,000 users of prescribed footwear (including people with conditions other than RA)

26. Current provision Including orthopaedic surgeons, orthotists, podiatrists occupational therapists and physiotherapists. professional boundaries do not always fit well within �health economy� groupings funding for orthosis and footwear provision organised variously through sometimes competing directorates within hospital trusts, PCTs and through commercial contracting. practice is often uncoordinated and incoherent attempts at wider service redesign undermined by lack of cohesion and drive to protect the status quo unacceptably wide variation in practice variable levels of effectiveness and satisfaction among people with RA receiving them potential for a waste of resources on a significant scale.

27. Previous reports 1992 Bowker�s Salford Report on orthotics services across the UK concluded that ��NHS Orthotics services are rudderless and one in which informed management, service audit and strategic planning have little place� 2

28. Audit Commission reports 2000 and 2002 progress in improving the orthotics service was �disappointing�. The organisation of orthotics services was :�a recipe for confusion, inequality and inefficiency� and �many equipment services were small and fragmented, characterised by a lack of clinical leadership and senior management involvement�, and �users did not always get equipment of a reasonable quality� The Commission called for urgent action

29. The Pathfinder Project 2004 - the NHS Purchasing and Supply Agency (PASA) Aimed at making the NHS an �intelligent customer� of orthotics services. The Agency concluded that it was not best placed to help deliver these changes as; �The structural, organisational and budgeting pressures, which prior to pathfinder restricted the orthotic services, re-emerged and crushed much of the pathfinder improvement.�

30. Future potential There are clear directions on areas for improvement Choice Information Design We can and must do better