Orthoses for Rheumatoid Arthritis James Carter Senior Orthotist

Presentation Outline The role of the Orthotist - including general orthotic principles Treatment options Accessing the service Q & A

Orthotist A clinician holding a BSc Hons degree in Prosthetics and Orthotics, diploma in orthotics or equivalent. Health Professions Council registered. Concerned with prescribing and fitting orthoses

Orthosis An externally applied device used to modify the structural or functional characteristics of the neuro-musculoskeletal system. (International Standards Organisation)

Terminology Orthoses are described according to the joints or body parts that they span. FO Foot Orthosis FFO Functional Foot Orthosis SMO Supra Malleolar Orthosis AFO Ankle Foot Orthosis KAFO Knee Ankle Foot Orthosis HKAFO Hip Knee Ankle Foot Orthosis

Orthoses Functions Correct/Accommodate deformity Protect against further deformity Pain relief – Limit motion/weight bearing Reduction of axial load Improve Function

Accommodate deformity and/or control motion

Functional Foot Orthosis Prevalent in JIA

Reducing pressure

Plantar Deformities

Total Contact Insoles

Pressure Redistribution Biomechanical Principles Total contact increases surface area and so reduces pressure Pressure transfer: remember if we offload one area we transfer that load to another area Interface conditions and the materials between soft tissue and applied force are critical Shear forces and impulse

Example Rheumatoid foot typically has a narrow heel and wide joint line (for obvious reasons). Normally won’t be accommodated satisfactorily in stock footwear

Three Stage Approach Short term - treatment Medium term – management Concerned with early wound care/prevention. Offloading devices, felt pads, simple insoles Medium term – management Concerned with correcting/accommodating foot position and healing wounds. Insoles and accommodative more versatile footwear Long term – prevention Concerned with ensuring at risk areas are maintained to their optimum position and function. Insoles and accommodative permanent footwear

Dorsal Deformities

Accommodative Footwear Cuff Fastenings Tongue Facings Heel clip Tabs Throat Heel counter Vamp Toe box Rear quarters Heel Mid sole Sole Toe spring/rocker Photo courtesy of Denovo Healthcare

Footwear Variations Photo courtesy of Dacey Orthotic Services

Footwear Adaptions SACH Heel Soft insert in the heel of a shoe Accommodates rigidity of the ankle Aids shock absorption

Footwear Adaptions Rocker Sole Reduces forefoot pressure Facilitates forward progression

Considerations Needs holistic approach May concentrate on mechanical deficit but outcomes guided by multifaceted input including any other medical aspect, lifestyle, activity level, beliefs and customs etc. Indoor/outdoor ratio Balancing the need for supportive footwear with “traditions” of slippers indoors. Body Image Acceptance of advise regarding not wearing certain styles of footwear. Any device has to reflect the anatomical shape.

Conclusion Recognise RA based deformity and options of treatment in terms of short, medium and long term goals. Can the issue be corrected or accommodated? How? Aim to reduce point pressure or loading, reduce time of load, reduce shear forces. Effects of weight line over base of support. Variety of options available - stock or bespoke footwear for example Refer directly to the appropriate Orthotic Service or through Consultant, GP or Allied Health Professional.

Thank you Any Questions

Information Useful link National Rheumatoid Arthritis Society - http://www.nras.org.uk/ Their footwear information section. Contact details: James Carter Senior Orthotist & Clinical lead Orthotic Service Local Care Centre Mount Gould Hospital PL4 7PY 01752 434229 email: james.carter2@nhs.net Photos/pictures unacknowledged on slides are courtesy of Gary Parfett, Prosthetic & Orthotic Service Manager