1. Orthoses for Rheumatoid Arthritis
James Carter
Senior Orthotist

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

3. 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

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

5. 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

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

7. Accommodate deformity and/or control motion

8. Functional Foot Orthosis
Prevalent in JIA

9. Reducing pressure

10. Plantar Deformities

11. Total Contact Insoles

12. 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

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

14. 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

15. Dorsal Deformities

16. 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

17. Footwear Variations
Photo courtesy of Dacey Orthotic Services

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

19. Footwear Adaptions Rocker Sole Reduces forefoot pressure
Facilitates forward progression

20. 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.

21. 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.

22. Thank you
Any Questions

23. Information Useful link
National Rheumatoid Arthritis Society -
Their footwear information section.
Contact details: James Carter Senior Orthotist & Clinical lead
Orthotic Service Local Care Centre
Mount Gould Hospital
PL4 7PY
Photos/pictures unacknowledged on slides are courtesy of Gary Parfett, Prosthetic & Orthotic Service Manager