November 2010

Choosing shoes for RA

In the moment: Footwear

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Therapeutic designs are a tough sell

By Jordana Bieze Foster

Despite research supporting the use of therapeutic shoes in patients with rheumatoid arthritis, a study from New Zealand suggests that only 5% of patients actually wear prescribed footwear.

The lack of compliance may be related to practitioners’ failure to understand the social and emotional implications of therapeutic footwear for patients—particularly women—with RA, according to a second study from the U.K.

Both studies were published in the October issue of the Journal of Foot & Ankle Research.

Researchers from Aukland University of Technology in New Zealand analyzed footwear selection in 80 patients with RA over a three-month period. More than 80% of participants were female, and the median disease duration was 11 years. Subjects’ “current footwear” choices were based on the shoes worn to a single research assessment session.

Researchers rated subjects’ footwear as good, average, or poor according to criteria established by Boston University researchers in an October 2009 foot pain study published in Arthritis & Rheumatism. Poor footwear included styles that lack support and structure; sandals were included in this category, although that was seen as a potential limitation of the study by some critics.

In the Aukland study, only 30% of subjects wore footwear that was classified as “good,” including the four patients (5% of the total study population) who wore therapeutic footwear at the time of assessment. The “poor” footwear category included sandals (33% of the total population), flip-flops (known to Kiwis as “jandals,” 10%), pumps  (or “court shoes,” 14%), and moccasins (5%).

The predominance of open-toed footwear may have been related to the timing of the study, which was conducted during the Southern Hemisphere’s summer months. However, the authors noted that the factors cited most often as influencing footwear choice were comfort and fit, suggesting that if patients are selecting “poor” shoes because they fit well and are comfortable, perhaps that category needs to be redefined.

Nevertheless, the results suggest that RA patients are largely resistant to wearing therapeutic shoes, in spite of evidence that such footwear can help improve symptoms. A 1997 Arthritis Care & Research study from Australia found that off the shelf orthopedic footwear was associated with significant improvements in pain and function after two months in 15 RA patients compared to a control group.

A 2007 Rheumatology study from the University of Salford in the U.K. found that 12 weeks of wearing traditional therapeutic footwear did not significantly affect clinical outcomes, but that a new therapeutic shoe designed according to patient preferences did. In that study, 10 of the original 80 subjects withdrew from the study even before being fitted for the footwear (nine in the traditional footwear group) because they did not like its appearance, and 10 more withdrew after fitting (again, nine in the traditional group) because they did not like the footwear.

This drop-out trend was not lost on the Salford researchers, who subsequently set out to examine in more detail the factors influencing RA patients’ acceptance of therapeutic footwear. In their October study, they qualitatively analyzed interviews with 30 female RA patients who had been wearing prescribed footwear for at least six months.

The most striking theme of the interviews was that the women viewed therapeutic footwear not just as an intervention but as a final and symbolic marker of their disease—a disease they can no longer keep hidden because their shoes give them away. The women’s descriptions of their interactions with the dispensing practitioners suggested that the practitioners did not appreciate the sensitivity of this issue.

Many women noted that the social stigma they associated with the shoes often outweighed the footwear’s functional benefits.

“They improve my mobility but restrict my activities,” one woman said.

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