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Table 3 Recommended guidelines for established RA

From: Clinical practice guidelines for the foot and ankle in rheumatoid arthritis: a critical appraisal

Guidelines Multi-disciplinary team care
ARMA Standards of care for people with inflammatory arthritis [33] People with inflammatory arthritis should have ongoing access to local multi-disciplinary team (GCP)
Podiatry is part of the multi-disciplinary team (GCP)
Ottawa Panel evidence-based clinical practice guidelines for electrotherapy & thermotherapy interventions in the management of RA in adults [40]  
Structural evaluation in the management of patients with RA: Development of recommendations for clinical practice based on published evidence and expert opinion [44]
BSR Guidelines on standards of care for persons with RA [46] Podiatry is part of the multi-disciplinary team (GCP)
Early referral for surgical opinion if required (GCP)
PRCA Standards of care for people with MSK foot health problems [34]  
Diagnosis and Treatment of RA [42]
Clinical Practice Guidelines for non-drug treatment (excluding surgery) in RA [43]
BSR and BHPR Guidelines for the management of RA (after the first 2 years) [48]
NICE RA National clinical guideline for management and treatment in adults [49]
Clinical practice guidelines for the management of RA in Spain [52]
NWCEG Guidelines for the management of the foot health problems associated with RA [35] Referral for surgery opinion should be offered as an alternative to therapeutic footwear referral (GCP)
Optimum ulcer management can only be achieved by a holistic and integrated multi-disciplinary team approach (GCP)
Contact the patient’s consultant/CNS immediately if the patient is being managed with biologic therapy and develops an ulcer and/or infection (GCP)
Red flags requiring urgent referral–tendon rupture, septic arthritis, suspicion of cancer (GCP)
EULAR recommendations for the use of imaging of the joints in the clinical management of RA [41]  
Guidelines Access to foot healthcare
ARMA Standards of care for people with inflammatory arthritis [33] 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 multi-disciplinary team member (GCP)
Ottawa Panel evidence-based clinical practice guidelines for electrotherapy & thermotherapy interventions in the management of RA in adults [40]
Structural evaluation in the management of patients with RA: Development of recommendations for clinical practice based on published evidence and expert opinion [44]
BSR Guidelines on standards of care for persons with RA [46] When clinically indicated access to podiatry should be available within 6 weeks of referral (GCP)
PRCA Standards of care for people with MSK foot health problems [34] Timely access to foot healthcare – diagnosis, assessment and management (GCP)
Adequate information/education should be given for self-management and signs/symptoms of deterioration in foot health and need to access specialist help promptly (GCP)
Diagnosis and Treatment of RA [42]  
Clinical Practice Guidelines for non-drug treatment (excluding surgery) in RA [43] Every patient with RA should be informed of the rules of foot hygiene and of potential benefit of referral to a podiatrist (GCP)
  A podiatrist should be consulted to treat nail anomalies and hyperkeratoses on the feet of patients with RA (GCP)
BSR and BHPR Guidelines for the management of RA (after the first 2 years) [48]  
NICE RA National clinical guideline for management and treatment in adults [49] All patients with RA and foot problems should have access to a podiatrist (GCP)
Clinical practice guidelines for the management of RA in Spain [52]  
NWCEG Guidelines for the management of the foot health problems associated with RA [35] Referral to a podiatrist is an integral part of the early management of RA patients (GCP)
EULAR recommendations for the use of imaging of the joints in the clinical management of RA [41]  
Guidelines Foot health assessment/review
ARMA Standards of care for people with inflammatory arthritis [33]  
Ottawa Panel evidence-based clinical practice guidelines for electrotherapy & thermotherapy interventions in the management of RA in adults [40]  
Structural evaluation in the management of patients with RA: Development of recommendations for clinical practice based on published evidence and expert opinion [44] Investigations to monitor course of RA should include radiographs of forefeet and should be done every 6 months in the first year, then every year to the third year and every 2–4 years thereafter (GCP)
BSR Guidelines on standards of care for persons with RA [46]  
PRCA Standards of care for people with MSK foot health problems [34] Foot healthcare providers must understand consequences of systemic disease on the feet and be able to identify warning signs that require timely referral to specialist medical care (GCP)
  Foot health assessment should occur within 3 months of diagnosis–doesn’t have to be done by foot health specialist (GCP)
  Annual review of foot health needs are desirable–doesn’t have to be done by foot health specialist (GCP)
  Where there is substantial change (better/worse) in disease activity, foot health should be reviewed (GCP)
Diagnosis and Treatment of RA [42]  
Clinical Practice Guidelines for non-drug treatment (excluding surgery) in RA [43] Feet, footwear and orthoses should be regularly examined (GCP)
BSR and BHPR Guidelines for the management of RA (after the first 2 years) [48]  
NICE RA National clinical guideline for management and treatment in adults [49] All patients with RA and foot problems should have access to a podiatrist for assessment and periodic review of their foot health needs (GCP)
Clinical practice guidelines for the management of RA in Spain [52]  
NWCEG Guidelines for the management of the foot health problems associated with RA [35] All patients should be referred for foot health assessment with 3 months of diagnosis with RA (GCP)
  All people with RA and foot problems should have access to a podiatrist for assessment and periodic review of their foot health needs (GCP)
  Patients with RA diagnosis should be assessed as soon as possible after diagnosis for lower limb and foot structural problems (GCP)
EULAR recommendations for the use of imaging of the joints in the clinical management of RA [41] Feet x-rays initial imaging technique to detect damage. Ultrasound and/or MRI should be considered if x-rays do not show damage and may be used to detect earlier damage (GCP)
  MRI or ultrasound detected synovitis and joint damage detected by x-rays, MRI or ultrasound can be considered for prediction of further joint damage (C)
  Periodic evaluation of joint damage should be considered. MRI (and possibly ultrasound) can be used to monitor disease progression (C)
  MRI and ultrasound detected inflammation predicts subsequent joint damage, even with clinical remission and can assess persistent inflammation (C)
Guidelines Orthoses/insoles/splints
ARMA Standards of care for people with inflammatory arthritis [33]  
Ottawa Panel evidence-based clinical practice guidelines for electrotherapy & thermotherapy interventions in the management of RA in adults [40]  
Structural evaluation in the management of patients with RA: Development of recommendations for clinical practice based on published evidence and expert opinion [44]  
BSR Guidelines on standards of care for persons with RA [46]  
PRCA Standards of care for people with MSK foot health problems [34]  
Diagnosis and Treatment of RA [42] Insoles may have a beneficial effect on pain in people with RA and foot complaints (A)
Clinical Practice Guidelines for non-drug treatment (excluding surgery) in RA [43] Customised toe splints may be preventive, corrective or palliative to enable the wearing of shoes (GCP)
  Customised orthotic insoles are recommended in the case of weight-bearing pain or static foot problems (GCP)
  Orthoses should be regularly examined (GCP)
  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 (A)
BSR and BHPR Guidelines for the management of RA (after the first 2 years) [48] Functional insoles should be available to all people with RA if indicated (A)
NICE RA National clinical guideline for management and treatment in adults [49] Insoles may have a beneficial effect on pain in people with RA and foot complaints (A)
Clinical practice guidelines for the management of RA in Spain [52] Hard orthotics improve pain in the hindfoot in the initial phase of the disease (A)
  Use of a special model can prevent the development and progression of hallux valgus (A)
  All patients with RA and foot pain should be considered for foot orthoses advice, irrespective of disease duration (B)
NWCEG Guidelines for the management of the foot health problems associated with RA [35] Patients with established foot deformity should be assessed for accommodative foot orthoses (C)
  Functional foot orthoses should be provided where tarsal joints are unaffected (B)
  Accommodative/cushioned orthoses should be provided when structural foot deformity, painful symptoms and activity restriction present (C)
EULAR recommendations for the use of imaging of the joints in the clinical management of RA [41]  
Guidelines Therapeutic footwear
ARMA Standards of care for people with inflammatory arthritis [33]  
Ottawa Panel evidence-based clinical practice guidelines for electrotherapy & thermotherapy interventions in the management of RA in adults [40]  
Structural evaluation in the management of patients with RA: Development of recommendations for clinical practice based on published evidence and expert opinion [44]  
BSR Guidelines on standards of care for persons with RA [46]  
PRCA Standards of care for people with MSK foot health problems [34]  
Diagnosis and Treatment of RA [42] Specially selected footwear may have a beneficial effect on pain in people with RA and foot complaints (B)
  Prescribing shoe adjustments and provisions must be considered in patients with RA and foot complaints (B)
Clinical Practice Guidelines for non-drug treatment (excluding surgery) in RA [43] Patients should be advised about footwear (GCP)
  Footwear should be regularly examined (GCP)
  Extra-width off-the-shelf or therapeutic thermoformed shoes are recommended when the feet are deformed and painful, if shoes are difficult to put on, or other footwear types have failed (C)
  Such shoes reduce pain on walking and improve functional capacity (GCP)
  Palliative customised therapeutic shoes may be prescribed when feet are seriously affected (GCP)
BSR and BHPR Guidelines for the management of RA (after the first 2 years) [48] Semi-rigid orthotic supportive shoes can be effective for metatarsalgia–reduction in pain, disability, and improvement in activity as measured by the FFI have been reported (B)
NICE RA National clinical guideline for management and treatment in adults [49] Therapeutic footwear should be available to all people with RA if indicated (D)
Clinical practice guidelines for the management of RA in Spain [52] Shoes with extra width improve the result of orthotics (A)
NWCEG Guidelines for the management of the foot health problems associated with RA [35] All patients with RA and foot pain should be considered for therapeutic footwear advice, irrespective of disease duration (B)
  Patients with established foot deformity should be assessed for accommodative footwear advice/specialist footwear (B)
  Footwear assessment and advice should be given to all patients (GCP)
  Patients struggling with retail footwear due to deformity should be offered the option of referral for therapeutic footwear. They should be informed of potential benefits and limitations of this footwear in respect to cosmesis (B)
EULAR recommendations for the use of imaging of the joints in the clinical management of RA [41]  
Guidelines Other treatments
ARMA Standards of care for people with inflammatory arthritis [33]  
Ottawa Panel evidence-based clinical practice guidelines for electrotherapy & thermotherapy interventions in the management of RA in adults [40] Low-level laser therapy is beneficial for pain relief in the feet (B)
Structural evaluation in the management of patients with RA: Development of recommendations for clinical practice based on published evidence and expert opinion [44]  
BSR Guidelines on standards of care for persons with RA [46]  
PRCA Standards of care for people with MSK foot health problems [34]  
Diagnosis and Treatment of RA [42]  
Clinical Practice Guidelines for non-drug treatment (excluding surgery) in RA [43]  
BSR and BHPR Guidelines for the management of RA (after the first 2 years) [48]  
NICE RA National clinical guideline for management and treatment in adults [49]  
Clinical practice guidelines for the management of RA in Spain [52]  
NWCEG Guidelines for the management of the foot health problems associated with RA [35] Callus should be assessed in relations to symptoms and causative factors before debridement is considered (GCP)
  Fungal infections (of the nail and skin) must be investigated and treated. If left untreated they can lead to ulceration and secondary bacterial infection. Discussion with the patient’s GP or consultant advised before systemic treatment is instigated (GCP)
  Consultant advice should be taken on ingrown toenails if the patient is being managed with a biological therapy and where there are signs of clinical infections and/or need for nail surgery (GCP)
  Patient education should include foot health self management advice and if necessary demonstration, explanation of foot problems and their impact on the individual, information on general disease management and signposting for future foot health needs (GCP)
  Consider steroid injection therapy for targeting localised, inflamed joints when the general disease is controlled (only in absence of sepsis) (GCP)
  Injection therapy should be seen as an adjunct to conventional podiatric management in combination with attempts to correct any structural deformity using orthoses (GCP)
EULAR recommendations for the use of imaging of the joints in the clinical management of RA [41]  
  1. A = Grade of recommendation based on systematic reviews; B = Grade of recommendation based on randomised controlled trials; C = Grade of recommendation based on quasi-experimental studies; D = Grade of recommendation based on non-experimental descriptive studies; GCP = Good Clinical Practice based on expert opinion