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Table 2 Guidelines and recommendations for foot related non-pharmacological interventions in established rheumatoid arthritis.

From: Looking through the 'window of opportunity': is there a new paradigm of podiatry care on the horizon in earlyrheumatoid arthritis?

  American College of Rheumatology Subcommittee on rheumatoid arthritis guidelines for the management of rheumatoid arthritis [73] Arthritis and Musculoskeletal Alliance Standards of care for people with inflammatory arthritis [74] Podiatry Rheumatic Care Association Standards of care for people with musculoskeletal foot health problems [75] National Institute for Health and Clinical Excellence Rheumatoid arthritis National clinical guideline for management and treatment in adults [76] British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the management of rheumatoid arthritis (after the first 2 years) [77] Clinical Practice Guidelines for non-drug treatment (excluding surgery) in rheumatoid arthritis [40]
Multidisciplinary team care   People with inflammatory arthritis should have ongoing access to local multidisciplinary team Podiatrists are part of the multidisciplinary team. Early referral for surgical opinion if required    
Access to foot health care   All people with a sudden 'flare-up in their condition should have direct access to specialist advice and the option for early review with the appropriate multidisciplinary team member Timely access to foot health care - diagnosis, assessment and management Adequate information/education should be given for self-management and signs/symptoms of deterioration in foot health and need to access specialist help promptly All patients with RA and foot problems should have access to a podiatrist   Every patient with RA should be informed of the rules of foot hygiene and of potential benefit of referral to a podiatrist A podiatrist should be consulted to treat nail anomalies and hyperkeratoses on the feet of patients with RA
Foot health assessment/review    Foot health care providers must understand the consequences of systemic disease on the feet and be able to identify warning signs that require timely referral to specialist medical care Musculoskeletal foot health assessment should include: General health; Foot health; Systemic factors; Lifestyle/Social factors; Pain management; Need for other assessments as required Foot health assessment should occur within 3 months of diagnosis - doesn't have to be done by foot health specialist Annual review of foot health needs are desirable - doesn't have to be done by foot health specialist Where there is substantial change (better/worse) in disease activity, foot health should be reviewed All patients with RA and foot problems should have access to a podiatrist for assessment and periodic review of their foot health needs   Feet, footwear and orthoses should be regularly examined
Orthoses/Insoles/Splints Non-pharmacological treatment recommendations include joint protection but do not specifically mention orthoses    Functional insoles and therapeutic footwear should be available to all people with RA if indicated Limited evidence for the use of foot orthoses - no consensus regarding choice of orthoses but reduction of pain and improved function of the foot are reported Customised orthotic insoles are recommended in the case of weight-bearing pain or static foot problems Customised toe splints may be preventive, corrective or palliative to enable the wearing of shoes Orthoses should be regularly examined
Therapeutic footwear      Semi-rigid orthotic supportive shoes can be effective for metatarsalgia - reduction in pain, disability, and improvement in activity as measured by the Foot Function Index have been reported Patients should be advised about footwear Footwear should be regularly examined Extra-width off-the-shelf or therapeutic shoes thermoformed on the patient's foot are recommended when the feet are deformed and painful, or if it is difficult to put on shoes - such shoes reduce pain on walking and improve functional capacity Off-the-shelf therapeutic thermoformed shoes for prolonged use are indicated when other types of footwear have failed Palliative customized therapeutic shoes may be prescribed when the feet are seriously affected