A MULTIDISCIPLINARY FOOT CLINIC

J. Woodburn , D.E. Turner , H.J. Davys , P.S. Helliwell HealthQWest, Glasgow Caledonian University, Glasgow, Department of Podiatry, University of Huddersfield, Huddersfield, Foot Health Department, The General Infirmary at Leeds, Academic Unit of Musculoskeletal Disease, University of Leeds, Leeds, United KingdomFoot problems in the rheumatic diseases are common, under-researched and frequently neglected, yet we know they impact negatively on health-related quality of life [1,2]. In the UK, the podiatrist may be well-placed to assess, advise and intervene and this is reflected in current guidelines such as the Scottish Intercollegiate Guidelines Network [3]. However, the podiatrist is only one member of the multidisciplinary team and the delivery of an effective foot care programme requires the expertise of a range of medical, surgical and allied health professionals [1,4].The main part of the presentation will compare, contrast and reflect on two models of hospital out-patient based foot care services which are: (1) podiatry led, and (2) consultant rheumatologist led [4]. Both models utilise a number of clinical specialities including the rheumatologist, orthotist, podiatrist and orthopaedic surgeon within the multidisciplinary team but consult differently. The podiatry led care programme provides ongoing palliative care for patients with well established foot impairments such as pain, stiffness and deformity. For example, this could include the provision of functional orthoses, scalpel debridement to painful calluses, footwear advice and foot health promotion. The podiatrist also has the lead role for a number of specialist clinics. These include, for example, the foot ulcer and minor surgery clinics along with dedicated services for patients with connective tissue disease and RA patients who attend the 'resistant disease' clinic for biologic treatment. Where appropriate, foot care can also be redirected to primary care under the supervision of community based podiatrists. The podiatrist coordinates rapid investigations such as diagnostic ultrasound and gait analysis to facilitate treatment planning and evaluation. Importantly, multidisciplinary team input is managed by the podiatrist but delivered for the most part in the outpatient clinics of each discipline.The rheumatologist led service, by contrast, uses a multidisciplinary team consulting together with the patient present [4]. RA patients are the largest patient group and foot pain and deformity are the most common impairments. A range of treatments are provided including customised orthoses, specialist footwear and adaptations, walking aids and referral for orthopaedic surgery [4]. As part of this presentation, the author will present audit data for the rheumatology led service and clinical trial data from a phase I study investigating the clinical effectiveness of the podiatry-led service.These two UK models represent 'best practice', however the experiences from colleagues in other parts of Europe will also be discussed. In the UK, recent evidence suggests inadequate implementation of best practice or current standards of care [5]. For example, in the Leeds study, less than 50% of rheumatologists reported an adequate provision of basic foot care and significant regional variation was observed. This is disappointing since two recent systematic reviews of foot care interventions in rheumatoid arthritis reach a positive conclusion for the use of foot orthoses, specialist footwear and orthopaedic surgery, whilst recognising that better trials are required [6,7]. The presentation will elaborate on these issues.Finally, the presentation will discuss current and future challenges for multidisciplinary foot health care provision in rheumatology. For example, the need for podiatry foot screening and interventions strategies for RA patients treated with biologic agents are being recognised following recent reports of associated foot complications (infection and ulceration) [8,9]. Other key issues such as extended podiatry roles in foot surgery will be discussed.References: 1. Woodburn J, Helliwell PS. Foot problems in rheumatology. Br J Rheumatol 1997;36:392-4.2. Wickman AM, Pinzur MS, Kadanoff R, Juknelis D. Health-related quality of life for patients with rheumatoid arthritis foot involvement. Foot Ankle Int 2004;25:19-26.3. Scottish Intercollegiate Guidelines Network. Management of Early Inflammatory Arthritis. SIGN publication No.48. Dec 2000.4. Helliwell PS. Lessons to be learned: a review of a multidisciplinary foot clinic in rheumatology. Rheumatology (Oxford) 2003;42:1426-7.5. Redmond AC, Waxman R, Helliwell PS. Provision of foot health service in rheumatology in the UK. Rheumatology (Oxford) 2005; Nov 30 [Epub ahead of print].6. Bowen CJ, Burridge J, Arden N. Podiatry interventions in the rheumatoid foot. B J Pod 2005;8:76-82.7. Farrow SJ, Kingsley GH, Scott DL. Interventions for foot disease in rheumatoid arthritis: a systematic review. Arthritis Rheum 2005;53:593-602.8. Otter S, Robinson C, Berry H. Rheumatoid arthritis, foot infection and tumour necrosis factor alpha inhibition - a case history. Foot 2005;15:117-9.9. Davys HJ, Woodburn J, Bingham SJ, Emery P. Onychocryptosis (ingrowing toenail) in rheumatoid arthritis patients on biologic therapy. Abstract submitted to the British Society for Rheumatology Annual Conference, May 2-5 2006, Glasgow, UK.Citation: Ann Rheum Dis, volume 65, supplement II, year 2006, page 8Session: Advances in multidisciplinary team care