Lower Extremity RA: Can Orthoses Have An Impact?
There is no other disease that so profoundly deforms the human foot as rheumatoid arthritis (RA). The pain symptoms from RA foot deformities limit mobility significantly in patients from adolescents to seniors. Although diabetes affects a greater number of people in the United States, the morbidity from RA is more severe. A podiatrist’s expertise in the mechanical treatment of the rheumatoid foot is not only a professional obligation but also a guarantee of continued referrals from the rheumatology professions. Intimate knowledge of orthotic control provides a unique opportunity to demonstrate our ability to reduce pain and increase mobility through custom functional foot orthoses (CFOs). What You Should Know About The Pathology Of RA Rheumatoid arthritis affects 2.1 million Americans with the disease affecting 2.5 times more women than men.1 The onset predominantly occurs during middle age but one may see RA in children and senior adults as well. Rheumatoid arthritis accounts for 22 percent of all deaths from arthritis and irreversible damage occurs early, often during the first two years of the disease.2,3 Rheumatoid arthritis is an inflammatory arthropathy with an etiology that is not entirely understood. Some researchers believe genetic factors play a major role but preliminary results from twin studies do not support this concept. The pathology has been described as two interrelated processes. The first process is the malfunctioning of the body’s immune system triggered by viral/bacterial infection or environmental toxins like caffeine and nicotine. The second process is chronic inflammation of joints leading to destruction of cartilage and subchondral bone. According to the Arthritis Foundation, the pathology begins when the body’s immune systems mounts an attack on joint tissue, particularly the synovium, producing destructive inflammatory cells and new blood vessel growth (angiogenesis) in the joint space. Certain types of T cells behave abnormally in this response and researchers are accordingly testing agents that block these particular T cells by inhibiting their receptors.4 A Primer On Systemic Treatment Options Systemic treatment of RA falls into several categories, which are all designed to reduce joint pain and swelling, relieve stiffness and prevent further joint damage. Traditionally, the first line of attack is nonsteroidal antiinflammatory drugs (NSAIDs). Low-dose corticosteroids are traditionally the second level of therapy for progressive symptoms and inflammation. This therapy has the obvious disadvantages of further immune suppression and adrenal suppression. Accordingly, this therapy is only utilized for short-term therapy. Recently, disease-modifying antirheumatic drugs (DMARDs) have demonstrated a curious success and have now stimulated several large clinical trials of methotrexate and leflunomide. These drugs control rapidly growing cells, hopefully the ones producing the inflammation, and the joint destruction. Antibiotic and anti-malarial drugs also seem to have a profound effect in some individuals yet have no effect in others. Investigations into biologic response modifiers (BRMs), drugs that inhibit certain cytokines that cause the actual joint destruction, have produced some optimism for future therapies. These new therapies as well as the emerging research are available at www.arthritis-research.com. What The Research Reveals About Orthotic Efficacy Given that most podiatrists do not initiate drug therapy for RA patients, our predominant role involves monitoring the patient’s progress, consulting with rheumatologists and providing mechanical and surgical care for the foot and ankle pathology. Recent significant research has been published about the value of mechanical control with custom foot orthoses. Understanding this recent research is vital for improved clinical outcomes and is also of interest to the rheumatologist who refers RA patients. A 1999 study examined RA patients with second MPJ plantar pain. Comparing prefabricated and custom functional orthoses, the authors of the study assessed the effectiveness of CFOs in reducing plantar pressure via a metatarsal pad in comparison to a metatarsal bar.