Powww.567.com

RESEARCHOpenAccessGuidelinesforthemanagementofpeoplewithfoothealthproblemsrelatedtorheumatoidarthritis:asurveyoftheiruseinpodiatrypracticeAnitaEWilliams1*,AndreaSGraham1,SamanthaDavies2andCatherineJBowen3AbstractBackground:Inthelastdecadetherehasbeenasignificantexpansioninthebodyofknowledgeontheeffectsofrheumatoidarthritis(RA)onthefootandthemanagementoftheseproblems.
Alignedwiththishasbeenthedevelopmentofspecialistclinicalrolesforpodiatrists.
However,despitebeingrecommendedbynationalguidelines,specialistpodiatristsarescarce.
Inordertoinformnon-specialistpodiatristsoftheappropriateinterventionsforthesefootproblems,managementguidelineshavebeendevelopedanddisseminatedbyagroupofspecialistpodiatrists.
Theaimofthissurveywastoinvestigatetheuseoftheseguidelinesinclinicalpractice.
Method:Followingethicalapprovalanonlinequestionnairesurveywascarriedout.
Thequestionswereformulatedfromafocusgroupandcomprisedfixedresponseandopenresponsequestions.
Thesurveyunderwentcognitivetestingwithtwopodiatristsbeforebeingfinalised.
Aninductiveapproachusingthematicanalysiswasusedwiththequalitativedata.
Results:245questionnaireswerecompleted(128–non-specialistworkingintheprivatesector,101non–specialistsworkingintheNHSand16specialistpodiatrists).
Overall,97%ofthenon-specialists(n=222)hadnotheardoftheguidelines.
Thenon-specialistsidentifiedotherinfluencesontheirmanagementofpeoplewithRA,suchastheirundergraduatetrainingandprofessionalbodybranchmeetings.
Threemainthemesemergedfromthequalitativedata:(i)thebenefitsofthefoothealthmanagementguidelines,(ii)thebarrierstotheuseofguidelinesgenerallyand(iii)thefeaturesofuseableclinicalguidelines.
Conclusions:Thisstudyhasrevealedsomecrucialinformationaboutpodiatrists'levelofengagementwiththefoothealthmanagementguidelinesandtheuseofguidelinesingeneral.
Specifically,thenon-specialistpodiatristswerelesslikelytousethefoothealthmanagementguidelinesthanthespecialistpodiatrists.
Thepositiveaspectswerethatforthespecialistpractitioners,theguidelineshelpedthemtoidentifytheirprofessionaldevelopmentneedsandforthefewnon-specialiststhatdidusethem,theyenabledappropriatereferraltotherheumatologyteamforfoothealthmanagement.
ThebarrierstotheiruseincludedalackofunderstandingoftheriskassociatedwithmanagingpeoplewithRAandthatguidelinescanbetoolonganddetailedforuseinclinicalpractice.
Suggestionsaremadeforimprovingtheimplementationoffoothealthguidelines.
Keywords:Guidelines,RheumatoidArthritis,FootHealth,Podiatry*Correspondence:a.
e.
williams1@salford.
ac.
uk1DirectorateofProsthetics,OrthoticsandPodiatry,UniversityofSalford,PO29BrianBlatchfordBuilding,SalfordM66PU,UKFulllistofauthorinformationisavailableattheendofthearticleJOURNALOFFOOTANDANKLERESEARCH2013Williamsetal.
;licenseeBioMedCentralLtd.
ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.
org/licenses/by/2.
0),whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
Williamsetal.
JournalofFootandAnkleResearch2013,6:23http://www.
jfootankleres.
com/content/6/1/23BackgroundInthelastdecadetherehasbeenasignificantexpansioninthebodyofknowledgeontheeffectsofrheumatoidarthritis(RA)onthefoot.
Thisresearchhasgrownfromearlypioneeringwork[1,2]andprovidesevidenceforthepathophysiologyoffootproblems[3-5],thealteredbiomechanics[6,7],thephysicaleffects[8]andthescaleoftheseproblems[9,10].
Furthertothis,thereisnowagreaterunderstandingoftheimpactonthepersonlivingwithfeetaffectedbyRA[11-13].
Foothealthmanage-menthasalsobeenthefocusofresearchthathasinves-tigatedspecificinterventions[14,15],thetimingoftheseinterventions[16]andthemeasurementoffoothealthoutcomes[17,18].
Alignedwiththisincreaseinevidenceandunderstand-ingoftheimpactofRAfootproblems,hasbeenthedevel-opmentofspecialistclinicalrolesforpodiatrists.
Askeycliniciansinvolvedinthemanagementoffootpathologies,ithasbeenrecommended[19-21]thatpodiatristsareincludedascoremembersofthemultidisciplinaryteamalongsideconsultantrheumatologists,specialistnurses,physiotherapistsandoccupationaltherapists.
Insomesec-ondarycarerheumatologyunitsintheUK,specialistpodi-atristshaveexpandedtheirrolesthroughfurthermedicalandspecialisttrainingtoincludeextendedscopepracticessuchasinjectiontherapy,ultrasoundimaging[22]andpharmacology.
Someroleshaveevolvedthatarefurtherspecialisedwiththefocusonspecificareasofrheumatol-ogy,suchasfoothealthmanagementforpeoplewhoarereceivingbiologictherapies.
However,thereisevidencethatalackofsuchspecial-istpodiatristsmeansthatthereareinsufficientnumberstomeettheneedsoftheRApopulation[23-25]withtheresultsthatmanypeoplewithRAseekfootcarefromnon-specialistpodiatrists.
ThesepodiatristshavegeneralprofessionalknowledgeandskillsbuthavenottakentheroutetospecialisationeitherthroughformaltrainingorthroughwhatBaconandBorthwick[26]describeas'charismaticauthority'.
Eitherrouteprovidesthead-vancedknowledgeandskillsnecessarytomanagepeoplewithRA,whichisnotthecaseforthenon-specialists.
Thisisofconcernbecauseofthecomplicationsassoci-atedwiththeautoimmunityandconcomitantdrugman-agement,inparticularthebiologictherapieswhichmayleadtomanifestationofinfectionand/orsevereulcer-ationwithinthefootandsystemicinfection[27].
Thiscreatesaseriousthreattobothfootandsystemichealth.
Fromthepatientsperspective,theyidentifythebenefitsofbeingmanagedbyspecialistpodiatristsandreportthattheseriousnessoffootproblemscanbeignoredbythosewhodonothavesucharole[12].
Thenumberofspecialistpodiatristswithinrheumatol-ogyisunlikelytoincreaseinthecurrentclimatewithintheUKNationalHealthService(NHS)[28].
However,theneedforfoothealthmanagementremainsconstant,despiteimprovedmedicalmanagementofRA[10].
Itisknownthatintheabsenceofspecialistpodiatrists,pa-tientswillseekfoothealthmanagementfromnon-specialists,eitherwithintheNHSorintheprivatesector[12,29]InordertosupportpodiatristsintheirmanagementofpeoplewithRArelatedfootproblems,guidelineshavebeensystematicallydevelopedbyapodiatryledclinicaleffectivenessgroupintheNWregionoftheUK(NWCEG)[30].
Theseguidelinesprovideevidencebased(andwhereevidencewaslacking,consensusbased)stan-dardsforfoothealthmanagementandascreening/refer-ralpathwaytoguidereferralsincaseswherefootproblemsaredeterioratingorareimpactinggeneraldis-easemanagement.
TheNWCEGguidelineshavebeenwidelydissemi-natedthroughoutthepodiatryprofessionintheUKthroughundergraduateandpostgraduateeducationalprogrammes,conferencepresentations,andpublications.
However,whatwasnotknownwaswhethertheguide-lineswerebeingused.
Theprimaryaimofthisstudytherefore,wastoinves-tigatepodiatrists'awarenessoftheNWCEGguidelines,theiruseofthemandtheperceivedbenefitsofusingthem.
Further,weaimedtoinvestigateifotherRAfo-cussedguidelines[19,21]influencedtheirpracticeandwhatotherinfluencesinformedtheirmanagementofpeoplewithRArelatedfootproblems.
Wealsoaimedtoascertainiftherewereanybarrierstotheimplementa-tionofguidelinesgenerallyandwhatareconsideredtobefeaturesofusableguidelineswithintheclinicalcon-text.
Toachievetheseaimsasurveyquestionnairewasusedtocollectbothquantitativeandqualitativedata.
MethodFollowingethicalapprovalfromtheUniversityofSalfordethicscommittee,theonlinequestionnaire(BristolOn-lineSurveyhttp://www.
survey.
bris.
ac.
uk/)wasdesignedasaresultofafocusgroup,withnon-specialistpodia-trists(n=6),specialistpodiatrists(n=2)andacademiccolleagueswithaspecialistinterestinrheumatology(n=2)asparticipants.
Thequestionthattriggeredthedialoguewas,"Whatdoweneedtoknowinordertoen-suretheeffectivetheuseoftheNWCEGGuidelines"Thedialoguewasdigitallyrecordedandthentranscribedverbatim.
Thetranscriptionwasthenanalysedusingastructuredframework[31]andthekeythemesagreedbytheparticipants.
Thequestionswereformulatedfromthemesidentifiedfromanalysisofthefocusgroupdata,withopenre-sponsequestions(qualitativedata)[18]andfixedre-sponsequestions(quantitativedata)[n=4],inordertoWilliamsetal.
JournalofFootandAnkleResearch2013,6:23Page2of8http://www.
jfootankleres.
com/content/6/1/23providethekeyfeaturesoftheparticipants,suchasage,genderandeducationallevel.
Themainfocusofthequestionswereinrelationtotheparticipant'sknowledgeofthecurrentlyavailableguidelinesrelatedtomanagementoffoothealthprob-lemsassociatedwithRA(withthefocusbeingtheNWCEGguidelines)[30].
TheNWCEGguidelinesare'practitionerfacing'inthattheyaimtoguidethepracti-tionerthroughtheassessmentandmanagementaspectsoffootcare.
However,theArthritisandMusculoskeletalAlliance(ARMA)[19]andthePodiatryRheumaticCareAssociation(PRCA)[21]guidelineswerealsoincluded.
Therationaleforthiswasthatalthoughtheseare'pa-tientfacing',thatis,theyaimtodefinewhatapersonwithRAcanexpectfromfoothealthservices,theyalsocontainstatementsinrelationtothepodiatristsroleinfoothealthmanagement.
Inaddition,otherquestionsre-latedtowhetherpodiatristsadheredtotheguidelinesinclinicalpractice,iftherewereanyotherinfluencesontheirmanagementofpeoplewithRA,whattheyper-ceivedthebenefitsofguidelinesareandwhattheycon-sideredtobethebarrierstotheiruseinclinicalpractice.
Participantswerealsoaskedtoidentifywhethertheydeemedthemselvesaseither,aspecialistpodiatristinrheumatologyworkingwithintheUKNHS,anon-specialistpodiatristworkingwithintheUKNHSoranon-specialistpodiatristworkingwithintheUKprivatesector.
Twonon-specialistpodiatristscompletedcogni-tivetestingofthequestionnaire.
Thepurposeofthiswastocheckfortheclarityofthequestions,thepositioningofthequestionswithinthequestionnaireandthetimetocompleteit(approximately15mins).
Nochangesweredeemednecessary.
TheonlinesurveywaspromotedthroughaformalpresentationattheUKSocietyofChiropodistsandPo-diatristsannualconferencein2011(attendeesN=1076).
Thesurveywasavailableforthedelegatestocompleteonthecomputersavailableattheconference.
Addition-ally,fliersweredistributedwiththestudydetailsandsurveylinksothatifdelegatescouldcompletethesur-veylateriftheywantedto.
Theonlinesurveyclosedsixmonthsfollowingtheconference.
Quantitativedataobtainedfromthesurveyquestion-naireswereanalysedusingdescriptivestatistics.
Anin-ductiveapproachusingthematicanalysiswasusedwiththequalitativedata[31]inordertoformulatethemes.
Exemplarsfromthetranscriptswereextractedtoillu-minatethesethemes.
Debateandagreementonthethemeswasachievedbytwooftheauthors(AWandAG).
ResultsFrom245completedquestionnaires,52.
3%(n=128)werecompletedbynon-specialistpodiatristsworkingwithintheUKprivatesector,41.
2%(n=101)bynon-specialistpodiatristworkingwithintheUKNHSand6.
5%(n=16)byspecialistpodiatristinrheumatologyworkingwithintheUKNHS(Table1).
Overall,themajorityofthe'non-specialist'podiatristsrespondingtothesurveyindicatedthattheyhadnotheardofthenationalguidelines.
With99.
1%(n=227)reportingthattheyhadnotheardoftheARMAguide-lines[19],similarly96.
5%(n=221)hadnotheardofthePRCAguidelines[21],and96.
9%,(n=222)hadnotheardoftheNWCEGguidelines[30](Table2).
Whenaskedifguidelinesinfluencetheirclinicalprac-ticeinmanagingpatientswithrheumatoidarthritis(Table3),allofthenon-specialistpodiatristsidentifiedundergraduateeducationasbeingthemaininfluencewiththemorespecialistactivitiessuchasconferences,trainingcoursesandspecificweb-basedinformationbe-ingaccessedmorebythespecialistpodiatrists.
Thein-fluenceofguidelineswasoneoftheleastmentionedandwhentheywere,themajorityidentifiedtheNationalInstituteforClinicalExcellenceguidelines[20]asbeingtheonlyinfluence.
Followinganalysis,thequalitativedatawasorganisedintothreemainthemes.
Theme1-ThebenefitsoftheNWCEGfoothealthmanagementguidelinesOfthosepodiatriststhatindicatedthattheywerefulfill-ingtherecommendations,thevastmajoritywerethoseinspecialistpostsandtheirlevelofusewasreportedtobehigh.
InrelationtothebenefitsofusingtheNWCEGguidelines,thespecialistpodiatrists(S-NHS)indicatedthattheyhadimpactonthequalityofpatientcarethroughensuringthatpracticewasbasedonevidence;"AlthoughIspecialiseinthisareaInowfeelsecureinthatIamdoingthebestformypatientsinrelationtoapplyingthebestevidencetomypractice".
S-NHS14(age-35;gender-female;highesteducationallevel-MSc).
Andfurthertothis,theysupportdefensiblepractice;"…WiththeseIknowthatIampracticinginthemostdefensibleway.
.
.
.
IcanprovethatIampracticingtothestandardexpectedbasedonresearchevidence".
S-NHS5(age-40;gender-male;highesteducationallevel-MSc).
TheNWCEGguidelinesalsoimprovedthespecialistpodiatrists'confidenceinbeingabletomaintainservicesforthesepatients;"…TheguidelinesmeanthatIcandefendcontinuingthisservicetomymanager.
RheumatologyalwaysWilliamsetal.
JournalofFootandAnkleResearch2013,6:23Page3of8http://www.
jfootankleres.
com/content/6/1/23comessecondtodiabetesandthesehelptomaintainahighprofile".
S-NHS3(age-35;gender-female;highesteducationallevel-BSc(hons)).
Inadditiontotheirdirectmanagementofpatients,theguidelinesalsohelpedthemtoidentifytheirContinuingProfessionalDevelopmentneeds;"…Ihadn'tthoughtaboutusingsteroidinjectionsbeforeuntilIsawtheiruseintheguidelines…Ihavedonethetraininganduseitinpracticenow".
S-NHS4(age-34;gender-female;highesteducationallevel-BSc(hons)).
Forthe5non-specialistNHSandthe2non-specialistprivatepodiatristswhoreportedthattheywereusingtheNWCEGguidelines,thebenefitsareperceivedtobedif-ferenttothespecialistpodiatrists.
Theyrecognisedthattheguidelinescreeningandreferralpathwayhadhelpedthemtoensurethatthepatientswerebeingmanagedintherightlocation;".
.
.
.
.
helpedmetoidentifythosepatientsthatIcan'tmanageasIdon'tworkwithinarheumatologyteam".
NS-NHS5(age-29;gender-female;highesteducationallevel-BSc(hons)).
"…someofthepatientsarebestmanagedintherheumatologydepartment…thoseonthenewdrugsandthosethatneedfootsurgeryorfootwear".
NS-P1(age-42;gender-female;highesteducationallevel-BSc(hons)).
Further,thekeystandardshadsupportedtheimple-mentationofaspectsofmanagementthattheyhadlearnedaboutduringtheirundergraduatetraining,"IamworkingonmaintainingthesestandardsandusethemasreferencetosupportwhatIlearnedatuni….
Iwouldnothavedonethiswithoutthestandards".
NS-NHS2(age-24;gender-male;highesteducationallevel-BSc(hons)).
"…thekeymessageshelpmetoidentifythe'mustdo's…Ididknowaboutsomeofthesebutit'shardtorememberallfromtraining".
NS-P2(age-28;gender-female;highesteducationallevel-BSc(hons)).
Thebenefitstothespecialistpodiatristsareclearinthattheyhavebeenusedtosupportgoodqualitypatientcaresuchasroledevelopment,maintainingservices,de-fensiblepracticeandapplyingevidenceintopractice.
Fromthefewwhoarefulfillingthestandardsinnon-specialistposts,theNWCEGguidelineshadprovidedguidanceastothemostappropriatelocationofmanage-mentandasanaidememoirtoaspectsofmanagementTable1ParticipantdemographicsTotalparticipants(n=245)Non-specialistprivate(n=128)Non-specialistNHS(n=101)Specialist*(n=16)Gender99female76female10female29male25male6maleYearsqualified1-35(SD=7.
78)1-29(SD=8.
71)6-29(SD=6.
63)Qualification:Diploma29100BSc(hons)95896MSc428PhD002NumbersofpeoplewithRAmanagedeachweek1-10(SD=2.
48)5-28(SD=8.
02)15-45(SD=9.
34)*3withadditionalacademicpostsatuniversities;1fulltimeacademic.
Table2ParticipantsKnowledgeofGuidelinesGuidelineResponseNon-specialistprivate(n=128)Non-specialistNHS(n=101)SpecialistNHS(n=16)NWCEGneverheard120510Guidelines[30]readthembutnotactingonrecommendations6450fulfillingrecommendations2516ArthritisandMusculoskeletalAlliance(InflammatoryArthritis)[19]neverheard1271000readthembutnotactingonrecommendations111fulfillingrecommendations0015MusculoskeletalFootHealthStandards[21]neverheard123980readthembutnotactingonrecommendations521fulfillingrecommendations0115Williamsetal.
JournalofFootandAnkleResearch2013,6:23Page4of8http://www.
jfootankleres.
com/content/6/1/23thathadbeenforgottensincetraining.
Overall,bythosewhoknewaboutthem,themanagementguidelineswereidentifiedasbeingusefulinthecontextofdirectandin-directaspectsofpatientmanagement.
Theme2-BarrierstotheuseofguidelinesgenerallyNon-specialistpodiatristsidentifiedthattheylackedthetimeinclinicalpracticetoreadanyguidelines.
Further,theyidentifiedthatevenifguidelineswereread,therewaslittlepointtothemasthestandardscouldnotbemetduetolackofresourcesandlackoffundingforpro-fessionaldevelopment.
Someoftheprivatepodiatristspreferredtospendthetimeresearchingtheirownsourcesofinformationandmakingtheirowndecisions.
"Iprefertoresearchandmakemyowndecisions-Iamanautonomouspractitionerandguidelinesdon'tallowforclinicaljudgement".
NS-P20(age-54;gender-male;highesteducationallevel-BSc(hons)).
"Idon'tusethem.
.
.
donotagreewiththeuseofguidelines,theyinterferewithmyautonomy-theypreventmebeingabletomakeclinicaljudgementsforeachpatient…Idon'tthinkmypatientswouldhaveconfidenceinmeiftheyknewIusedthem".
NS-P30(age-55;gender-male;highesteducationallevel-BSc(hons)).
Anumberoftheprivatepodiatriststhoughtthatguidelineswerenotrelevanttotheirpractice;"Guidelinesaresomethingthatdon'treallyapplytomeinmypracticeasIfocusonbasictreatments".
NS-P35(age-45;gender-female;highesteducationallevel-BSc(hons)).
Thenon-specialistNHSpodiatristsreportedthattherewerejusttoomanyguidelinesandtherewereissuesinthewaythatguidelinesarelaidout;"…therearetoomanyguidelinesfromdifferentagenciesandoverlapininformation".
NS-NHS78(age-34;gender-female;highesteducationallevel-BSc(hons)).
"Theyaretoolongtoreadandit'shardtonavigatearoundwhatisimportantandwhatissupportinginformation….
alsotheyarenotthataccessible".
NS-NHS54(age-58;gender-female;highesteducationallevel-diploma).
Thespecialistpodiatristsfocussedonconcernsaboutpotentialconflictinprofessionalrolesforinterventionscontainedinguidelinessuchassteroidinjections,ratherthanthelayoutandcontent.
Theme3-ThefeaturesofuseableclinicalguidelinesTherewasagreementacrossallthreeparticipantgroupsthatreferralpathwayswereausefulclinicaltool.
How-ever,itwasthoughtthatguidelinesneedtobeupdatedonaregularbasisandoldonesremovedfromwebsitesandclinics.
Manyofthenon-specialistNHSgroupmen-tionedthatdiagramsandmappingagainstclinicalprac-ticewereuseful;"Diagramsarehelpfultounderstandkeyconceptssuchascorrectionofrearfootwithfootorthoses".
NS-NHS44(age-40;gender-male;highesteducationallevel-BSc(hons)).
"Theyneedtobeinalogicalsequence…proceduresneedtoreflectwhatgoesoninclinicalpractice".
NS-NHS56(age-25;gender-female;highesteducationallevel-BSc(hons)).
Withsummariesandkeypointsbeinghelpful:"Summarystatementsaregood…keypointsofessentialswithreferencebacktothemainsectionformoredetail".
NS-NHS34(age-46;gender-male;highesteducationallevel-MSc).
Table3Mostsignificantinfluencesonclinicalpracticeinrelationtomanagingpatientswithrheumatoidarthritis(participantswereaskedtotickallthosethatappliedtothem)Non-specialistprivate(n=128)Non-specialistNHS(n=101)SpecialistNHS(n=16)Undergraduateeducation12810116LocalSocietyofChiropodistsandPodiatristsbranchmeetings101552Readingscientificpapersinpeerreviewedjournals343016Guidelines165116Conferences155615Webbasedresourcese.
g.
ArthritisResearchUK10251Informalcontactwiththosespecialisinginthefield5120Trainingcourses(BSRFootandAnkleCourse)0213Williamsetal.
JournalofFootandAnkleResearch2013,6:23Page5of8http://www.
jfootankleres.
com/content/6/1/23Inrelationtothecontentofguidelines,additionalin-formationwassuggestedsuchas;"Howtoproceedifthepatientfallsoutsideoftheparametersoftheguidelines".
NS-P70(age-35;gender-female;highesteducationallevel-BSc(hons)).
"Resourcelinksforpatientinformationandlistsofcourseswhereyoucangettraining".
NS-NHS22(age-29;gender-male;highesteducationallevel-BSc(hons)).
"…Awayofauditingthestandardstoensurethattheyarebeingadheredtoandthenifnotitprovidesacaseforservicedevelopment".
NS-NHS1(age-42;gender-female;highesteducationallevel-BSc(hons)).
Oneparticipantsuggestedthatasummaryofotherrelevantguidelinesshouldbecontainedineachguide-lineandeachidentifiedastowhethertheyareusefulformanagers/clinicalleads,non-specialists,specialistsand/orpatients.
DiscussionThisstudyhasrevealedsomecrucialaspectsaboutpodia-trists'engagementinguidelinesofrelevancetotheman-agementofpeoplewhopresentwithfootproblemsrelatedtoRA,inparticulartheNWCEGguidelines[30].
Ithasdemonstratedthat,inrelationtoboththeknowledgeofanduseofRAguidelinesthereisanotabledifferenceinthattheUKspecialistpodiatristsarefarmorelikelytousetheguidelinesthanUKnon-specialistpodiatrists.
ThisisofconcernastheNWCEGguidelineswereintendedforallpodiatriststoensuretheappropriateandtimelyman-agementofRArelatedfootproblems.
Additionally,thereweredifferencesinresponsesinre-lationtobarrierstotheimplementationofguidelinesintoclinicalpractice,withthenon-specialistpodiatristsmorefrequentlyreportingdifficultiesininterpretingguidelines(cognitivebarriers)andhadlessfavourableopinionsaboutguidelines(affectivebarriers)thanspe-cialistpodiatrists.
Thefewnon-specialistsrecognisingbenefitscommentedmoreonhowtheysupportappropriatereferralstotherheumatologyteamforfoothealthmanagement,ratherthanguidingthemthroughtheirownmanagementofthepatient.
However,thisisbeneficialinrelationtothepa-tientreceivingtherightinterventionintherightsetting.
AfewdididentifythatadheringtotheguidelinessupporteddefensiblepracticebutitisofconcernthatsomethoughttheywerenotrelevanttotheirpracticeastheirtreatmentofpeoplewithRAwasverysimple,suchastoenailcut-ting.
Thisperhapsindicatesalackofknowledgeabouttheimplicationsofevensimplefootcareforthosepatientswhoareimmunologicallysuppressedand/orreceivingbio-logicaltherapyfortheirsystemicdisease,andinwhomskinandsofttissueinfectionsoccurmorefrequentlyandcandeveloprapidly[27].
Indeedthenon-specialistpodia-tristswerelesslikelytohaveundertakenpostgraduatequalificationsinthisarea.
Somenon-specialistpodiatristsconsideredthattheguidelinesdetractedfromtheirprofessionalautonomyandhencetheydidnotusethem.
NancarrowandBorthwick[32]haveproposedthatperceptionssuchasthesearisefromprofessionalisolationandmaybelinkedtoavoid-anceofmedicalhierarchies.
Thismayindicatethat,forthosepodiatrists,theirpracticeisnotdefendableintermsofnewparadigmsofmanagementofpeoplewithearlyRAdisease[16],asadvocatedwithintheguidelines.
Assuch,the'windowofopportunity'toensureearlydetectionandmanagementoffootproblemsforthesepatientsmaybemissed.
Incontrast,tothenon-specialistpodiatrists,thespe-cialistpodiatristswereusingtheguidelines.
However,theywerehamperedbyexternalbarrierssuchasalackofagreementabouttheirrolesandresponsibilitieswithinrheumatology,particularlyinrelationtointerven-tionsthathavetraditionallybeencarriedoutbythemedicalprofession.
ThisisconsistentwithRedmondetal.
[24]whoidentifiedwidevariationintheUKintheprovisionoffoothealthservicesandtrainingforspecial-istpodiatryrheumatologyservices.
Apositiveperspectivefromourstudywasthatthe'specialist'podiatristsstatedthatguidelineshelpedthemtoidentifytheirprofessionaldevelopmentneeds,specif-icallyinrelationtoadvancedskillsandalsohelpedthemprovideevidencefortheprovisionofaspecialistfoothealthserviceforpeoplewhohaveRA.
Afurtherdevel-opmentfromthiswouldbetheembeddingoffoothealthcarealgorithmsinclinicalpracticeaswellasthedesignandimplementationofanaudittoolbasedonthefoothealthguidelinesinordertoformallyevaluateservices.
Inrelationtousabilityofguidelines,thereweresomecommentsbythespecialistpodiatristsastohowthiscouldbeimproved.
Solutionstothecognitivebarriersmaybesimpleinrelationtothepresentationandformatoftheguidelines.
Thespecificsthatweresuggestedwerehavingasummaryofthekeyaspectsofthemanagementguidelinesinaseparatedocumentandalsoasummaryofallrelevantguidelineswithanindicationastowhotheyarerelevantto(managers,patients,podiatrists).
Also,itwassuggestedthatawayofauditingthestan-dardswouldbeusefulinordertoidentifygapsintrain-ingandserviceprovision.
Dodeketal.
[33]identifiedtheinfluencesontheim-plementationofguidelinesasbeingthequalityofevi-denceandthecredibilityoftheguidelinesdevelopmentWilliamsetal.
JournalofFootandAnkleResearch2013,6:23Page6of8http://www.
jfootankleres.
com/content/6/1/23group.
However,thesewerenotidentifiedasabarrierinthissurvey.
Oneofthecontextualfactorsthatseemtobeimplicitintheresultsofthissurveyistheinfluenceofthetypeofservice.
Dodeketal.
[33]furtheridentifiedthatsharedbeliefsaboutguidelinesandadherencetoguidelinerecommendationsmaybemoreevidentwithinteams.
Therefore,oneofthewaystoimprovetheuseofguidelinesistoensurepeersupportwherenon-specialistpodiatristsareworkinginisolation.
A'peersupportandreviewscheme'asrecommendedbyPiperetal.
[34]mayhelptosupportlinksbetweenthespecialistandnon-specialistservices.
Further,aservicethatprovidesseam-lesscarebetweenspecialistandnon-specialistservicescouldprovideopportunityforsupportandeducation[35].
LinekerandHusted[36]concludedthatitisdiffi-culttochangebehaviorandnotedthatrecentgraduatesmaybemorereceptivetoguidelineimplementation.
Therefore,itwouldbepertinenttoreinforcethebenefitsofusingtheguidelinesduringtheundergraduatetrain-ingofpodiatrists.
TherearesomelimitationstothisstudyinthatitwasdeliveredattheUKSocietyofChiropodistsandPodia-trist'sannualconferenceandsomaynotreflecttheopin-ionsofallpodiatristspractisingwithintheUK.
Further,theremaybepotentialbiasinthesurveysuchasacquies-centresponses,particularlyfromthespecialistpodiatrists.
Itwasalsoimpossibletoensurethatthesurveywasnotcompletedmorethanoncebyeachparticipantorthatanon-podiatristcouldhavecompletedit.
Alsoitwasimpos-sibletoensurethatitwascompletedbyequalnumbersofprivate,non-specialistNHSpodiatristsandspecialistpodi-atristsandsoitwasapragmaticandconvenientsample.
However,theproportionsofnon-specialist(93.
5%)tospe-cialist(6.
5%)podiatristswhocompletedthesurveyreflectthenationalprofileasidentifiedbyRedmondetal.
[24].
ConclusionWithinthisstudywehaveidentifiedanextremelyhighpercentageofnon-specialistpodiatristswhoareunawareoftheguidelinesforthemanagementoffoothealthproblemsforpeoplewhohaverheumatoidarthritis.
Therefore,implementationstrategiesneedtobeim-proved.
Contextualfactors,suchaspeersupport,auditandeducationmaysupporttheimplementationoftheguidelinesintonon-specialistpodiatrypractice.
ConsentInformationaboutconsentwasprovidedintheparticipantinformationsheetwhichtheyreadbeforecompletingthesurvey:'Bycompletingthesurveyyouareprovidingcon-senttobepartofthisresearchandforthepublicationoftheresults'.
Thesurveyand/oracopyoftheNWCEGGuidelinesfortheManagementofFootHealthforPeoplewithRheumatoidArthritiscanbeobtainedfromtheleadauthora.
e.
williams1@salford.
ac.
ukCompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.
Authors'contributionsAWconceivedofthestudyandledthedevelopmentofthesurvey,AGcontributedtothedevelopmentofthesurveyandqualitativedataanalysis,SDcontributedtothedevelopmentofthesurveyandCBparticipatedinitsdisseminationandhelpedtodraftthemanuscript.
Allauthorsreadandapprovedthefinalmanuscript.
AcknowledgementsMathewFitzpatrick,ChairofSCPconference2011,theSCPconferencecommittee,theNWCEGpodiatristsandthepodiatristswhocompletedthesurvey.
Authordetails1DirectorateofProsthetics,OrthoticsandPodiatry,UniversityofSalford,PO29BrianBlatchfordBuilding,SalfordM66PU,UK.
2PennineAcuteHospitalsNHSTrust,NorthManchesterGeneralHospital,DelaunaysRd,Crumpsall,ManchesterM85RB,UK.
3FacultyofHealthSciences,UniversityofSouthampton,Building45,SouthamptonSO171BJ,UK.
Received:7March2013Accepted:17June2013Published:18June2013References1.
SpiegelTM,SpiegelJS:Rheumatoidarthritisinthefootandankle–diagnosis,pathology,andtreatment.
Therelationshipbetweenfootandankledeformityanddiseasedurationin50patients.
FootAnkle1982,2(6):318–324.
2.
VidigalE,JacobyRK,DixonStAJ:Thefootinchronicrheumatoidarthritis.
AnnRheumDis1975,34(4):292–297.
3.
BowenCJ,HooperL,CullifordD,DewburyK,SampsonM,BurridgeJ,etal:Assessmentofthenaturalhistoryofforefootbursaeusingultrasonographyinpatientswithrheumatoidarthritis:atwelve-monthinvestigation.
ArthritisCareRes(Hoboken)2010,62(12):1756–1762.
4.
HulsmansHM,JacobsJW,vander-HeijdeDM,van-Albada-KuipersGA,SchenkY,BijlsmaJW:Thecourseofradiologicdamageduringthefirstsixyearsofrheumatoidarthritis.
ArthritisRheum2000,43(9):1927–1940.
5.
BarnR,TurnerDE,RaffertyD,SturrockRD,WoodburnJ:Tibialisposteriortenosynovitisandassociatedpesplanovalgusinrheumatoidarthritis:EMG,multi-segmentfootkinematicsandultrasoundfeatures.
ArthritisCareRes(Hoboken)2013,65(4):495–502.
6.
TurnerDE,HelliwellPS,SiegelKL,WoodburnJ:Biomechanicsofthefootinrheumatoidarthritis:identifyingabnormalfunctionandthefactorsassociatedwithlocaliseddisease'impact'.
ClinBiomech(Bristol,Avon)2008,23(1):93–100.
7.
TurnerDE,HelliwellPS,EmeryP,WoodburnJ:Theimpactofrheumatoidarthritisonfootfunctionintheearlystagesofdisease:aclinicalcaseseries.
BMCMusculoskeletDisord2006,21(7):102.
8.
HooperL,BowenCJ,GatesL,CullifordDJ,BallC,EdwardsCJ,etal:Prognosticindicatorsoffoot-relateddisabilityinpatientswithrheumatoidarthritis:resultsofaprospectivethree-yearstudy.
ArthritisCareRes(Hoboken)2012,64(8):1116–1124.
9.
vander-LeedenM,SteultjensMP,UrsumJ,DahmenR,RoordaLD,SchaardenburgDV,etal:Prevalenceandcourseofforefootimpairmentsandwalkingdisabilityinthefirsteightyearsofrheumatoidarthritis.
ArthritisRheum2008,59(11):1596–1602.
10.
GrondalL,TengstrandB,NordmarkB,WretenbergP,StarkA:Thefoot:stillthemostimportantreasonforwalkingincapacityinrheumatoidarthritis:distributionofsymptomaticjointsin1,000RApatients.
ActaOrthopaedica2008,79(2):257–261.
11.
OtterSJ,LucasK,SpringettK,MooreA,DaviesK,YoungA,etal:Identifyingpatient-reportedoutcomesinrheumatoidarthritis:theimpactoffootsymptomsonself-perceivedqualityoflife.
MusculoskeletalCare2012,10(2):65–75.
12.
WilliamsAE,GrahamAS:'Myfeet:visible,butignored'.
Aqualitativestudyoffootcareforpeoplewithrheumatoidarthritis.
ClinRehabil2012,26(10):952–959.
Williamsetal.
JournalofFootandAnkleResearch2013,6:23Page7of8http://www.
jfootankleres.
com/content/6/1/2313.
WechalekarMD,LesterS,ProudmanSM,ClelandLG,WhittleSL,RischmuellerM,etal:Activefootsynovitisinpatientswithrheumatoidarthritis:applyingclinicalcriteriafordiseaseactivityandremissionmayresultinunderestimationoffootjointinvolvement.
ArthritisRheum2012,64(5):1316–1322.
14.
HennessyK,WoodburnJ,SteultjensMP:Customfootorthosesforrheumatoidarthritis:Asystematicreview.
ArthritisCareRes(Hoboken)2012,64(3):311–320.
15.
SiddleHJ,RedmondAC,WaxmanR,DaggAR,Alcacer-PitarchB,WilkinsRA,etal:Debridementofpainfulforefootplantarcallositiesinrheumatoidarthritis:theCARROTrandomisedcontrolledtrial.
ClinRheumatol2013,32(5):567–574.
16.
WoodburnJ,HennessyK,SteultjensMP,McInnesIB,TurnerDE:Lookingthroughthe'windowofopportunity':isthereanewparadigmofpodiatrycareonthehorizoninearlyrheumatoidarthritisJFootAnkleRes2010,17(3):8.
17.
HelliwellP,ReayN,GilworthG,RedmondA,SladeA,TennantA,etal:Developmentofafootimpactscaleforrheumatoidarthritis.
ArthritisRheum2005,53(3):418–422.
18.
WalmsleyS,RaveyM,GrahamA,TehLS,WilliamsAE:Developmentofapatient-reportedoutcomemeasureforthefootaffectedbyrheumatoidarthritis.
JClinEpidemiol2012,65(4):413–422.
19.
ARMA:ArthritisandMusculoskeletalAlliance-StandardsofCareforpeoplewithInflammatoryArthritis.
2004.
cited;Availablefrom:http://www.
arma.
uk.
net.
20.
NICE:Guidanceforthemanagementofrheumatoidarthritisinadults.
;2009.
cited;Availablefrom:www.
nice.
org.
uk/nicemedia/pdf/CG79NICEGuideline.
pdf.
21.
PodiatryRheumaticCareAssociation:StandardsofCareforPeoplewithMusculoskeletalFootHealthProblems.
2010.
cited;Availablefrom:http://www.
prcassoc.
org.
uk/standards-project.
22.
BowenCJ,DewburyK,SampsonM,SawyerS,BurridgeJ,EdwardsCJ,etal:Musculoskeletalultrasoundimagingoftheplantarforefootinpatientswithrheumatoidarthritis:inter-observeragreementbetweenapodiatristandaradiologist.
JFootAnkleRes2008,1(1):5.
23.
NationalAuditOffice:ServicesforPeoplewithRheumatoidArthritis.
London:TheStationaryOffice;2009.
24.
RedmondAC,WaxmanR,HelliwellPS:ProvisionoffoothealthservicesinrheumatologyintheUK.
Rheumatology(Oxford)2006,45(5):571–576.
25.
RheumatologyFuturesGroup:Perceptionsofpatientsandprofessionalsonrheumatoidarthritiscare.
London:TheKingsFund;2009.
26.
BaconD,BorthwickAM:Charismaticauthorityinmodernhealthcare:thecaseofthe'diabetesspecialistpodiatrist'.
SociolHealthIlln2012.
doi:10.
1111/1467-9566.
12024.
27.
DixonWG,WatsonK,LuntM,HyrichKL,SilmanAJ,SymmonsDP,etal:Ratesofseriousinfection,includingsite-specificandbacterialintracellularinfection,inrheumatoidarthritispatientsreceivinganti-tumornecrosisfactortherapy:resultsfromtheBritishSocietyforRheumatologyBiologicsRegister.
ArthritisRheum2006,54(8):2368–2376.
28.
PrimaryCareRheumatologySociety:ExpertOpinionsinRheumatology:Issue2.
ThePCRSocietyGuidetoCommissioningMusculoskeletalServices.
Hertfordshire:ACPublications;2011.
29.
WilliamsAE,BowdenAP:Meetingthechallengeforfoothealthinrheumaticdiseases.
Foot2004,14(3):154–158.
30.
WilliamsAE,DaviesS,GrahamA,DaggA,LongriggK,LyonsC,etal:Guidelinesforthemanagementofthefoothealthproblemsassociatedwithrheumatoidarthritis.
MusculoskeletalCare2011,9(2):86–92.
31.
ColaizziPF:PsychologicalresearchasaPhenomenologistViewsIt.
InExistentialPhenomenologicalAlternativesforPsychology.
EditedbyValleRS,KingM.
NewYork:OxfordUniversityPress;1978:48–71.
32.
NancarrowSA,BorthwickAM:Dynamicprofessionalboundariesinthehealthcareworkforce.
SociolHealthIlln2005,27(7):897–919.
33.
DodekP,CahillNE,HeylandDK:Therelationshipbetweenorganizationalcultureandimplementationofclinicalpracticeguidelines:anarrativereview.
JParenterEnteralNutr2010,34(6):669–674.
34.
PiperH,HassellAB,RoweIF,DelamereJ:CommitteeWMRSaT.
Experienceofsixyearsofaregionalpeerreviewschemeinrheumatology.
Rheumatology(Oxford)2006,45(9):1110–1115.
35.
HetthenJ,HelliwellPS:Acomparisonbetweenprimarycare-ledrheumatologyservicesandsecondarycareprovision.
Rheumatology(Oxford)1999,38(12):1294–1295.
36.
LinekerSC,HustedJA:Educationalinterventionsforimplementationofarthritisclinicalpracticeguidelinesinprimarycare:effectsonhealthprofessionalbehavior.
JRheumatol2010,37(8):1562–1569.
doi:10.
1186/1757-1146-6-23Citethisarticleas:Williamsetal.
:Guidelinesforthemanagementofpeoplewithfoothealthproblemsrelatedtorheumatoidarthritis:asurveyoftheiruseinpodiatrypractice.
JournalofFootandAnkleResearch20136:23.
SubmityournextmanuscripttoBioMedCentralandtakefulladvantageof:ConvenientonlinesubmissionThoroughpeerreviewNospaceconstraintsorcolorgurechargesImmediatepublicationonacceptanceInclusioninPubMed,CAS,ScopusandGoogleScholarResearchwhichisfreelyavailableforredistributionSubmityourmanuscriptatwww.
biomedcentral.
com/submitWilliamsetal.
JournalofFootandAnkleResearch2013,6:23Page8of8http://www.
jfootankleres.
com/content/6/1/23