Case Study-Podiatry Definition of Rheumatoid Arthritis

Case Study: Podiatry
Podiatrists are essential healthcare practitioners in the diagnosis and treatment of Rheumatoid Arthritis (RA) (Helliwell, Siddle & Redmond, 2011). This paper explores the case study of a 48-year-old female patient who is complaining about stiffness and swelling of her joints; mostly on both of her forefeet and she is also having visible hallux abducto valgus (HAV) deformity. About two years ago, she was diagnosed with RA. The study will insightfully analyze the gold standard assessment as well as diagnosis of the actual and possible foot problems that are associated with her condition, from a podiatry perspective. This paper will also be discussing the definition and etiological understanding of the effects of Rheumatoid Arthritis, as well as how this may lead to the pathogenesis of structural and foot problems. The paper will include analysis of the gold standard assessment and application to her condition. Moreover, the paper will look at the underlying pathogenesis of the patient’s disease and how this has led her to develop HAV. Finally, this paper will discuss how taking a detailed history aids in ameliorating her quality of life as appropriate treatment options can be made to match her way of living.
Definition of Rheumatoid Arthritis
As stated by Turner and Woodburn (2008), Rheumatoid Arthritis (RA) is defined as a polyarthritis, systemic joint disease that comes with a chronic an auto-immune, inflammatory, random, symmetrical, and fluctuating course. It is an inflammatory illness that mainly affects a person’s synovial joints. The disease normally affects the small joints of the feet and hands, both sides evenly as well as symmetrically (Arthritis Research UK, 2017). Also, this systemic disease could affect the entire body, even the eyes, lungs and heart. In Britain, about 40,000 people have this disease. The incidence of RA is low with an estimated 3.6 women and 1.5 men per 10,000 people getting it annually, meaning that about 12,000 men and women develop the disease annually in Britain (Arthritis Research UK, 2017).
RA affect three times as many women than men, the common age is over 40 plus, but it can affect people at any age, there are other forms of inflammatory arthritis, but RA is the most common one, there are plus than 400,000 adults with Rheumatoid Arthritis in the UK and it represent about 1% of the UK population (NRAS, 2014). The severity of RA differs both within and between different individuals and although it may affect any joint in the body, it mostly affects the feet, hands, and wrists (Tan et al., 2003). The condition is costly both socially and economically. For instance, four out of every ten people working and have been diagnosed with the condition end up losing their jobs (Barn et al., 2013).
Important Component of RA In Relation To Management of This Patient as a Podiatrist
In relation to the management of this 48-year-old female RA patient as a podiatrist, the important components of RA include foot problems as she experiences pain in both feet. This patient was diagnosed with Rheumatoid Arthritis two years ago therefore, it is important for the podiatrists to understand some of the key components of RA. Foot problems that are linked to Rheumatoid Arthritis are rather prevalent. Even so, these problems have been under reported not just by patients, but also by the rheumatology team, and it is usually ignored in many clinical practice settings (Williams & Graham, 2012). Neglecting Rheumatoid Arthritis affects the diagnosis at the early phase and debilitates the need for appropriate interventions. Overall, delaying the referral of the Rheumatoid Arthritis patient to a Podiatrist could be damaging in our case to our patient.
Podiatry is part of the healthcare multidisciplinary team (MDT) working together in providing care for clients with inflammatory arthritis (National Rheumatoid Arthritis Society, 2010). The podiatrist’s roles necessitate assessing, diagnosing and treating patients who suffer from lower extremity problems. Podiatrists have specialized knowledge and skills in disorders of the foot and it has been identified that rheumatologists and patients can both benefit from the participation of a podiatrist (Korda and Balint, 2004). Nonetheless, even with evidence demonstrating the need for podiatry services (Williams & Bowden, 2004) and efforts for ensuring that PRCA Standards of Care and NICE recommendations are met, there are still problems with accessing podiatry services. Some of these problems include the fact that podiatry is a service that is under‐ resourced and underused, and there is no specialist podiatry service in many areas (Rheumatology Futures Group, 2009; National Audit Office report, 2009). Juarez et al. (2010) also observed restrictions of provision of specialist’s foot care services in a certain district hospital with only one in three patients being seen by a podiatrist specialist.
The patient in our case is categorized as high risk because of the autoimmune nature of the RA disorder. Rheumatoid Arthritis mainly affects the periarticular synovial structures and the synovial joints. The categorisation of RA as defined by Johns Hopkins Arthritis Research Center (2018) ‘an immune mediated inflammatory disease (IMID)’. In addition, Woodburn et al. (2010) outlined it as a result of auto-immune mediated thickening and inflammation of the synovium. This condition causes chronic inflammation of an individual’s joints in addition to inflammation of other areas of the body. The immune system of the body, which usually protects its health through attacking foreign substances such as viruses and bacteria, predominantly attacks the joints. The symptoms of this disease include loss of joint function, joint stiffness, joint swelling, and joint pain (Woodburn et al., 2010) which are all evident in the patient. Crevoisier (2006) argued that the deformity and destabilization of the structure of the foot in RA patient is a result from the inflammation of the synovial membrane. Subsequently, the foot is involved in more than 80% of people with RA, the most commonly region involved is the forefoot, and in particular the metatarsophalangeal (MTP) joints. In this patient she is complaining of pain in the forefeet and visible hallux abducto valgus (HAV) (Crevoisier, 2006).
Graham and Williams (2015) stated that nine out of ten individuals with RA have foot problems, resulting in decreased social participation, quality of life, mobility, and even function. The foot problems also have a negative impact on the person’s body image (Graham & Williams, 2015). Even so, these could be improved with patient education, footwear, orthoses, and general foot care. Researchers have also reported that in individuals with RA, foot pathology has a bio-psychosocial impact on their lives (Turner et al., 2006; Williams et al., 2013; Walmsley et al., 2012; Graham and Williams, 2015).
Key features in relation to things podiatrists need to know to make their practice safe
Multidisciplinary team (MDT) in addition to shared decision and patient education are crucial to the management of early arthritis (Comb, et al., 2016). Additionally, the healthcare professionals can make a huge difference to patients care and cost-effectiveness within the National Health Service (NHS) as stated by the Department of Health and cited in the NRAS website (NRAS, 2012). Prior to assessing the feet of this RA patient and caring for her, the MDT including the podiatrist should first understand the National Institute for Health and Care Excellence clinical guidelines (NICE 2015) and the 2016 Scottish Intercollegiate Guideline (SIGN 2016).
For this specific case study, the Gold Standards requirement for a podiatry care service outlined by the North West Clinical Effectiveness Guidelines Group (NWCEG, 2014) would be utilized. It will be used as the framework to clinically assess the condition of the patient and help her to manage her RA by reducing the pain in her feet, improving her foot function, mobility and quality of life using a safe and cost-effective treatment. As stated by Korda (2000), patients and rheumatologists should take advantage of the proficiency of podiatry services in caring for the treatment of the feet disorder.
The key to success in foot health care is good communication between health professionals and patients for decision making (NWCEG, 2014). The role of the podiatrist necessitates making people mobile and free of pain through giving advice on providing appropriate foot care, treating callosities and infections,footwear, and treating or preventing foot ulcers (Korda, 2000). Furthermore, over the past decade, a small number of podiatrists have specialized to be part of a clinical specialist team by pursuing further medical training in foot rheumatology and other extensive choices of practice such as diabetes, ultrasound imaging, and injection therapy (Williams et al., 2013). There are few Specialist Rheumatologist Podiatrists taking charismatic authority to care for the need of those who suffer from RA (Williams et al., 2013). However, according to Woodburn et al. (2010), early intervention from the podiatry team is important and is a “window of opportunity” to have a controlled and positive outcome and hence the shortage of specialist podiatrists needs to be addressed.
As a podiatrist for me to practice safely within my clinic, I will need to follow the HCPC code of conduct guidelines as well as NWCEG guidelines including the ‘Gold Standards’. Clinical assessments must be thorough and systematic. It is important to follow the screening and assessment process as this will ensure that proper management is done by the right healthcare practitioner. Podiatry referral pathway set up by the NW CEG team must be offered to the patient. According to the North-West NHS Podiatry Services Clinical Effectiveness Guidelines Group for the Management of Foot Health for People with Rheumatoid Arthritis, podiatry referral should be provided to every patient who has rheumatoid arthritis (Davies, 2014).
The guidelines also state that a baseline assessment has to include the following: full surgical and medical history including the duration of the illness; detailed assessment of lower limb and foot structure and function; general health and systemic factors, examination for indications of extra-articular features of disease – tenosynovitis, tendonitis, vasculitis, bursa, and nodules; medication and pain management; and move, look, and feel the foot to assess deformities, the foot position, range of movement and location of swollen, tender and painful sites (Davies, 2014).
The baseline assessment should also include sensation assessment with 10g monofilament as a minimum; vascular assessment basing upon patient’s symptoms and clinical signs, Doppler ultrasound offers an objective measurement of vascular status and should be used to assess foot pulses; and assessment of the patient’s chief presenting problem, chronological development of symptoms and the pattern of distribution (Davies, 2014). The impact of the problem, patient’s expectations and knowledge/perceptions should also be addressed. In addition, the baseline assessment includes assessment of nails, skin lesions, and tissue viability; assessment of the need for foot orthoses and pressure relief; examination of the footwear used by the patient and its appropriateness for outdoor and home use; assessment of the need for referral if the patient requires a surgical opinion or other members of the multidisciplinary team for instance orthotist, occupational therapist, or physiotherapist; as well as assessment of lifestyle and social factors including mobility/activity, occupation, alcohol use, smoking, neglect, and ability to self-care (Davies, 2014).
Besides the aforementioned basic standards, the following gold standard assessments will also have to be conducted: baseline measurements of health status, foot pain and function should be done with the use of measurement tools like the Salford Rheumatoid Arthritis Foot Evaluation Index, Leeds Foot Impact Scale or Foot Function Index; assessment of the impact of foot problems on the activities of daily living such as the capacity of the patient to find job or to continue in employment; assessment of tendon reflexes; use the DAS28 tool to assess disease activity; yearly review of the patient with RA; direct referral for MRI scans/ultrasound/x-rays for detailed assessment and diagnosis; and updating all the patient records consistent with these standards (Davies, 2014).
Various tools can be used for the analysis, for example musculoskeletal ultrasound which is harmless, painless and accessible for usage in the clinical environment. Ultrasound imaging enables timelier and better assessment of changes in soft tissues and joints because of inflammation linked to RA (Helliwell, Siddle & Redmond, 2011). Assessment also includes the application of techniques of clinical history; examination and gait analysis of the lower limb so as to diagnose those pathologies related to systemic disease, including differential diagnoses of the foot pathology such as Lyme disease, sarcoidosis, osteoarthritis, sjogren syndrome, fibromyalgia, relapsing polychondritis, systemic lupus erythematosus, psoriatic arthritis, myelodyplastic syndrome and paraneoplastic syndromes (Williams et al., 2013; Dartel et al., 2013). These signs and symptoms are different from those of RA in that a person with RA will not display such symptoms and signs. A person with RA will exhibit joint stiffness, joint swelling, joint pain, loss of joint range of motion, joint warmth, joint redness and joint tenderness (Barn et al., 2013).
A complete physical examination is done on the patient for the purpose of assessing synovitis, which include the presence and distribution of tender or swollen joints and limited joint motion; signs of diseases like psoriasis; and manifestations of extra-articular diseases like rheumatoid nodules (Helliwell, Siddle & Redmond, 2011). Medications for the management of the systemic disease include various classes of medicines such as biologics, corticosteroids, disease-modifying anti-rheumatic drugs (DMARDs), and nonsteroidal anti-inflammatory drugs (NSAIDs). It is of note that patient education typically begins at the point of assessment with the podiatrist providing patient education (PE) about all aspects of assessment so that the patient clearly understands why these are important, for example the implications of being on certain drugs such as Biologics; the implications for continuing to smoke, if she does; and why I am looking at circulation. Future management involves providing the patient with PE aimed at improving her health status, health behaviors, as well as long-term outcomes.
PE is a vital armory of rheumatoid arthritis management strategies, for ...