Focus on Glasgow
Published on 01 January 2009
Something’s afoot at Glasgow Caledonian University as a team of expert podiatrists work to improve painful feet in arthritis sufferers - largely funded by Arthritis Research UK.
“Feet are the window to your health,” says Jim Woodburn, and if anyone is qualified to make this pronouncement, it’s the Professor of Rehabilitation at Glasgow Caledonian University (GCU).
“If you have problems with your feet you probably have other health problems too,” he adds. “And a very high proportion of people with rheumatoid arthritis have painful feet problems; probably about 90 per cent of patients. Feet are a critical site for involvement in early disease.”
Jim Woodburn has spent a large part of his distinguished professional career as an academic podiatrist trying to get the medical and health professions to treat feet as seriously as they deserve to be.
Many people with rheumatoid arthritis (RA) describe how it feels like walking on broken glass, and looking at the pressure scans of their feet in Professor Woodburn’s office makes it clear why this is so. In RA the foot becomes deformed, and the toes rise off the floor so that the patient walks on the balls of their feet. Bursae, small fluid-filled sacs or calluses then form. Because there is no fatty padding beneath the foot to act as a cushion, the pressure on the ball of the foot increases, causing extreme pain and altering the walking pattern.
People with these sorts of foot deformities tend to compensate by walking more slowly and shuffling, which then causes problems elsewhere, such as weakness in the calf muscles. “A minor foot problem can cause major problems, and people often tell us that it really limits their activities,” says Jim Woodburn.
Despite the high prevalence of painful foot symptoms in RA, treatment around the UK remains fairly woeful. “It might be the patient’s chief concern but most rheumatologists often don’t routinely examine the feet as they would the hands, for example,” explains Dr Debbie Turner, the recently appointed arc senior lecturer at GCU. “Even if you are treated at a good rheumatology department, the feet are not included in many of the standard outcome measures of disease activity (the score used to assess how active RA is) unlike the hand, shoulder and knee, although the feet are commonly involved and the rate of joint destruction is very high.”
Podiatry services are very patchy
Podiatry services for patients with arthritis and musculoskeletal conditions are very patchy throughout the UK, from centres of excellence providing a first-rate podiatry service for patients, to absolutely no foot care provision whatsoever.
Amid this background, Jim Woodburn was appointed at GCU three years ago, after being funded by Arthritis Research UK and the Medical Research Council over a long period while at the University of Leeds.
He has since been gathering together a pool of expertise, including Dr Turner, whose Arthritis Research UK lectureship will run for five years, lecturer Ruth Semple, who has an Arthritis Research UK allied health professionals training fellowship, and PhD students Gordon Hendry, Elaine Hyslop and Lisa Newcombe. In total Arthritis Research UK is pumping more than £650,000 into the Foot and Ankle Research Group in a bid to build up academic podiatry.
There are no standard treatments for foot problems in RA
The team are also building up a Glasgow-wide approach to podiatry by establishing close links with rheumatologists involved in related musculoskeletal research: Arthritis Research UK Professor (and former chairman of trustees) Roger Sturrock and Professor Iain McInnes at Glasgow Royal Infirmary and Arthritis Research UK Clinical Senior Lecturer in paediatric rheumatology Dr Janet Gardner Medwin at the Royal Hospital for Sick Children at Yorkhill. Jim and Debbie are also supervising NHS physiotherapist Mhairi Brandon’s academic research as she works towards a consultant grade.
Jim Woodburn is aware that there are no standard treatments for foot problems in RA and only a very small established evidence base, although custom-made orthoses (insoles), steroid injections and ultimately surgery appear to work best.
High resolution pressure images of the ball of the foot showing (left) a normal foot and (right) the foot of an RA patient showing high spikes of pressure overlying damaged and deformed joints.
He and his team’s research programme is therefore a combination of academic research to find out more about the structure and biomechanics of the foot in inflammatory arthritis, and to improve the care and treatment of painful foot problems for patients. To do this the team aim to develop and test new treatments such as customised orthoses and specially designed footwear, and targeting stubborn or persistent inflamed areas, even when patients are doing well on medication.
Debbie Turner is enthusiastic about the use of ultrasound in the diagnosis, prognosis and treatment of inflammatory arthritis in the feet and is currently developing important skills in this still fairly new field. “With ultrasound you can look much more accurately to quantify disease activity and to find out about the relationship between inflammation and mechanical abnormality,” says Dr Turner. In another example of its versatility, using ultrasound can improve the accuracy of giving a steroid injection in the back of the foot from 60 per cent to more than 80 per cent leading to better results.
Arthritis Research UK recently awarded the team a new piece of equipment called a high resolution pressure measurement analysis system, which, when used in conjunction with diagnostic ultrasound, can provide a better understanding of the effects of inflammation on the structure and function of the foot.
The team employs 3-D motion tracking which uses special cameras to detect the movement of reflective markers on the patient’s foot and leg and a force-plate to build anatomical and functional models. This enables them to study in detail the complex movement, forces and pressures experienced by joints and muscles which are damaged in inflammatory joint disease.
Use of ultrasound is popular with patients
The use of diagnostic ultrasound and the foot pressure measurement analysis system is popular with patients. “It’s an invaluable tool from an educational point of view, as patients can see what is going on with their joints from looking at the images on the screen. Explaining what’s going on is always a crucial part of patient management,” says Debbie Turner. “If they can see from the ultrasound images that joints have been extensively damaged by their disease and that foot pressures overlying these joints are so extreme that they can’t be relieved effectively by any other means but surgery, then they are often far more willing to consider having foot surgery. So the equipment will help them make critical decisions based on evidence.”
Patients also benefit from attending the specialist monthly clinic at the gait lab at GCU and talking to the podiatry team, as it’s often the first time they have had an opportunity to speak about something that has been troubling them and disabling them for a long period of time. Debbie Turner is only too well aware of the hit and miss nature of podiatry provision in the UK and particularly in Scotland and is working with NHS colleagues to gather evidence and create a business case for more posts, following examples of best practice in NHS areas such as Fife, and Ayrshire and Arran.
A direct, practical effect on patient care
The team are already running two patient-oriented trials which could have a direct, practical effect on patient care. The first is a small scale preliminary trial, run by Ruth Semple, using ultrasound imaging to diagnose inflammation around the tendon at the back of the foot, and comparing the effectiveness of a custom-made insole which acts as a splint to stabilise the foot joints, compared to an ultrasound-guided injection of steroid. Treatment will be provided for three months. “This double-headed approach tackles both the mechanical and inflammatory factors that may be at the root of this problem,” explains Ruth.
Testing the effect of a new footcare package
The second, being run by Jim Woodburn with PhD student Gordon Hendry, involves up to 60 children and teenagers with painful feet as a result of their arthritis, and is being co-run with medics at Yorkhill and Glasgow Royal Infirmary. Of the 250 youngsters being treated at Yorkhill, only 18 have attended any podiatry services.
They are testing the effectiveness of a new foot-care package which ensures that patients receive treatment quickly, and uses various techniques to diagnose foot problems, including, inevitably, ultrasound. Some of the youngsters will also be offered steroid injections, personalised orthoses, exercises and physiotherapy. The team are hopeful that these measures will make their foot problems more treatable and less painful.
“The joints that are affected are still growing, and inflammation in growing joints can cause quite significant deformity,” explains Gordon Hendry. “Some kids with arthritis have really severe, rigid feet and may require multiple surgery before the age of 20. We’re trying to raise awareness of this problem as well as trying to improve treatment for these youngsters.”
Professor Woodburn is well aware that academic podiatry is still a new medical specialty and may take some time to take its place among more established areas like rheumatology. He knows there’s so much to be done, and is aware that his team simply can’t do everything that’s needed. Nevertheless he is rightly proud of his young team and what they are achieving. “We’re one of the most productive groups in the university,” he says, and you get the feeling there’s a lot more to come.