The role of the orthotist in the management of arthritis
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1 AOPA Evidence Statement no. 3: The role of the orthotist in the management of arthritis Providing foot and knee orthoses to reduce pain and improve quality of life 0 P age
2 About the Australian Orthotic Prosthetic Association The Australian Orthotic Prosthetic Association (AOPA) is the peak professional body for orthotist/prosthetists in Australia. AOPA self regulates the profession through the establishment of standards, codes and guidelines which are upheld by AOPA certified practitioners Our certified practitioners are qualified orthotist/prosthetists employed throughout the public and private sectors. They provide the full range of orthotic and prosthetic clinical care to support mobility, quality of life, rehabilitation, and participation goals of their clients. AOPA s mission is to self regulate the profession to ensure the delivery of safe and effective orthotic and prosthetic care in Australia. AOPA also has a role in member representation and the delivery of member benefits, which contributes to the growth of the profession, the shaping of clinical services and maintaining a profession of excellence. For more information about the Australian Orthotic Prosthetic Association, visit The Australian Orthotic Prosthetic Association 2016 Disclaimer: The Australian Orthotic Prosthetic Association has taken care to ensure that at the date of publication, information within this document is accurate, up to date and free from errors, however it may not cover all relevant aspects of the role of the orthotist in the management of arthritis, dependent upon how the information is being utilised. The AOPA therefore does not make any warranty about the accuracy, reliability, currency or completeness of the material contained within the document. The AOPA and any individual or organisation associated with the preparation of this document disclaim any and all liability associated with any loss the user of this document may suffer as a result of reliance on the document. Individuals should exercise their own independent skill and judgment before relying on this document. 1 P age
3 Key message Osteoarthritis and rheumatoid arthritis are the most common cause of severe long term pain and negative physical impact in Australia Orthotic management of arthritis reduces pain, improves mobility and may delay the need for surgery Orthotists are the only allied health professional qualified to provide the full range of orthosis options to support people suffering from arthritis Arthritis in Australia One of the most common long term diseases Arthritis is one of the most common long term diseases in Australia, affecting more than 3.1 million Australians or 15.2% of the total population 1. Rheumatoid arthritis is an autoimmune disease that results in joint destruction and permanent deformity, most commonly in the hands and feet. Rheumatoid arthritis affects approximately 2% of the population and while the prevalence of rheumatoid arthritis peaks in older females, the disease may occur at any age 1. Osteoarthritis is characterized by loss of joint cartilage primarily in the knees and hips and affects an estimated 8% of people, most commonly females in the later years of life 1. Due to increasing obesity and an ageing population, the number of people living with the disabling effects of arthritis is increasing. It is estimated that by the year 2050, 7 million Australians will suffer from some form of arthritis 2. Pain and mobility loss in arthritis sufferers The most common cause of severe long term pain and negative physical impact Rheumatoid arthritis and osteoarthritis are the most common cause of severe long term pain and negative physical impact in Australia 1. Almost one third of people with arthritis, or 1 million Australians report some core activity restrictions 1. Arthritic pain in the feet, knees and hips limits activity and participation and results in a decreased quality of life 3. For advanced arthritis, joint damage becomes so severe that joint replacements and fusions become necessary. Accordingly, osteoarthritis is the major underlying factor in the need for joint replacements 1. 2 P age
4 The cost of arthritis Disability and poor quality of life impose substantial costs on society Rheumatoid arthritis and osteoarthritis are a major cause of health expenditure in Australia, responsible for expenses of approximately $1.4 billion in , with associated indirect costs estimated at triple this amount 2. People with arthritis experience considerable disability, psychological distress and poor quality of life 4, 5, which also affects their families and carers 6. The burden imposed on society is substantial poor workforce participation is a common experience for people with chronic disease 7. Orthotic intervention in the management of arthritis Orthoses help relieve pain in people suffering from arthritis As most forms of arthritis have no known cure, the focus of health care is on effective strategies for relieving pain and maintaining mobility. Orthotic intervention is a common conservative treatment option for people with rheumatoid arthritis and osteoarthritis and has been the subject of several Cochrane 8 11 and systematic reviews Osteoarthritis Osteoarthritis sufferers often experience pain from both cartilage degeneration and knee malalignment. Knee malalignment and associated pain may be reduced by the use of foot orthoses which alter knee alignment by changing the position of the tibia (lower leg bone). Foot orthoses may reduce pain 8 and are more effective when orthotic treatment is started early: the less severe the osteoarthritis is at the time of initial presentation, the more effective the orthotic intervention 21. Knee orthoses (often known as unloaders: figure 1) provide direct biomechanical control over the knee to reduce malalignment and pain. Knee pain can also be reduced by using softer circumferential knee sleeves. Knee orthoses increase the distance a client can walk 8 and may delay the need for surgical intervention, relieving pain while waiting for surgery 22. Literature suggests these orthoses may assist in decreasing pain, joint stiffness, and drug dosage and may also improve proprioception, balance, condylar separation and physical function scores 12. Knee orthoses Figure 1. A knee orthosis encompasses the knee joint and may extend up the femur (thigh bone) and/or down the tibia/fibular (lower leg bones). Knee orthoses for people with osteoarthritis include unloaders (pictured image source: JointPainInfo) which provide a direct biomechanical effect to the knee joint, and knee sleeves which provide circumferential support. 3 P age
5 Rheumatoid arthritis In people with rheumatoid arthritis, foot deformity results in areas of localised increased pressure, callousing and pain. Custom made foot orthoses (figure 2) aim to accommodate foot deformity, thereby relieving pressure and pain. Numerous systematic reviews have unanimously concluded that foot orthoses significantly reduce pain 10, 11, 16 20, pressure 17 and increase physical function 19 in people with rheumatoid arthritis. Foot orthoses Figure 2. A foot orthosis encompasses the whole or part of the foot 31 and is worn in the shoe against the sole of the foot. Foot orthoses can be made from a variety of materials including hard plastic and varying densities of foam. Foot orthoses are used to redistribute pressure, provide pain relief and realign joints of the foot, ankle and entire lower limb. The position of the Australian Orthotic Prosthetic Association For clients with osteoarthritis or rheumatoid arthritis, the provision of custom made knee or foot orthoses help reduce pain and improve mobility. Numerous clinical guidelines recommend custom foot orthoses for people with rheumatoid arthritis and foot and knee 27, 28, 30 orthoses for people with osteoarthritis. In Australia, orthotists are the only allied health professionals who are qualified to clinically assess, prescribe, design, fit and review orthoses for the whole body, to support clients with arthritis. Access to orthotists in both the primary and secondary health care settings is essential to improve client outcomes and minimize the burden of disease associated with arthritis in Australia. 4 P age
6 Image used with permission from Ossur OA Injury Solutions 5 P age
7 References 1. AIHW. A snapshot of arthritis in Australia. Canberra: Australian Institute of Health and Welfare, Access Economics Pty Ltd. The prevalence, cost and disease burden of arthritis in Australia. Canberra: Access Economics Pty Ltd, Jakobsson U, Hallberg IR. Pain and quality of life among older people with rheumatoid arthritis and/or osteoarthritis: a literature review. Journal of Clinical Nursing. 2002; 11(4): AIHW. A snapshot of rheumatoid arthritis. Canberra: Australian Institute of Health and Welfare, AIHW. A picture of osteoarthritis in Australia. Canberra: Australian Institute of Health and Welfare, Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bulletin of the World Health Organization. 2003; 81(9): AIHW. Chronic disease and participation in work. Canberra: Australian Institute of Health and Welfare, 2009 Contract No.: Cat. no. PHE Brouwer RW, van Raaij TM, Jakma TT, Verhagen AP, Verhaar JA, Bierma Zeinstra S. Braces and orthoses for treating osteoarthritis of the knee. The Cochrane Library Duivenvoorden T, Brouwer RW, van Raaij TM, Verhagen AP, Verhaar JA, Bierma Zeinstra S. Braces and orthoses for treating osteoarthritis of the knee. The Cochrane Library Hawke F, Burns J, Radford JA, du Toit V. Custom made foot orthoses for the treatment of foot pain. The Cochrane Library Egan M, Brosseau L, Farmer M, Ouimet MA, Rees S, Tugwell P, et al. Splints and orthosis for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2001; 4: Raja K, Dewan N. Efficacy of knee braces and foot orthoses in conservative management of knee osteoarthritis: a systematic review. American Journal of Physical Medicine & Rehabilitation. 2011; 90(3): Reilly K, Barker K, Shamley D. A systematic review of lateral wedge orthotics how useful are they in the management of medial compartment osteoarthritis? The Knee. 2006; 13(3): Malvankar S, Khan WS, Mahapatra A, Dowd GS. Suppl 3: How Effective are Lateral Wedge Orthotics in Treating Medial Compartment Osteoarthritis of the Knee? A Systematic Review of the Recent Literature. The open orthopaedics journal. 2012; 6: Parkes MJ, Maricar N, Lunt M, LaValley MP, Jones RK, Segal NA, et al. Lateral wedge insoles as a conservative treatment for pain in patients with medial knee osteoarthritis: a meta analysis. Jama. 2013; 310(7): Conceição CSd, Gomes Neto M, Mendes SM, Sá KN, Baptista AF. Systematic review and meta analysis of effects of foot orthoses on pain and disability in rheumatoid arthritis patients. Disability & Rehabilitation. 2014; (preprint): Hennessy K, Woodburn J, Steultjens MP. Custom foot orthoses for rheumatoid arthritis: a systematic review. Arthritis care & research. 2012; 64(3): Farrow S, Kingsley G, Scott D. Interventions for foot disease in rheumatoid arthritis: a systematic review. Arthritis Care & Research. 2005; 53(4): Oldfield V, Felson DT. Exercise therapy and orthotic devices in rheumatoid arthritis: evidence based review. Current opinion in rheumatology. 2008; 20(3): Loveday DT, Jackson GE, Geary NP. The rheumatoid foot and ankle: current evidence. Foot and Ankle Surgery. 2012; 18(2): Shimada S, Kobayashi S, Wada M, Uchida K, Sasaki S, Kawahara H, et al. Effects of disease severity on response to lateral wedged shoe insole for medial compartment knee osteoarthritis. Archives of physical medicine and rehabilitation. 2006; 87(11): Wilson B, Rankin H, Lowry Barnes C. Long term results of an unloader brace in patients with unicompartmental knee osteoarthritis. Orthopedics. 2011; 34(8): Luqmani R, Hennell S, Estrach C, Birrell F, Bosworth A, Davenport G, et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (the first two years). Rheumatology. 2006; 45(9): Forestier R, André Vert J, Guillez P, Coudeyre E, Lefevre Colau M M, Combe B, et al. Non drug treatment (excluding surgery) in rheumatoid arthritis: clinical practice guidelines. Joint Bone Spine. 2009; 76(6): Gossec L, Pavy S, Pham T, Constantin A, Poiraudeau S, Combe B, et al. Nonpharmacological treatments in early rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion. Joint Bone Spine. 2006; 73(4): Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care & Research. 2012; 64(4): Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence based, expert consensus guidelines. Osteoarthritis and Cartilage. 16(2): Jordan KM, Arden NK, Doherty M, Bannwarth B, Bijlsma JWJ, Dieppe P, et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Annals of the Rheumatic Diseases. 2003; 62(12): Gélis A, Coudeyre E, Hudry C, Pelissier J, Revel M, Rannou F. Is there an evidence based efficacy for the use of foot orthotics in knee and hip osteoarthritis? Elaboration of French clinical practice guidelines. Joint Bone Spine. 2008; 75(6): The National Collaborating Centre for Chronic Conditions. Osteoarthritis: National Clinical Guidelines for Care and Management in Adults. London, UK: Royal College of Physicians; International Organisation for Standards. Prosthetics and orthotics Vocabulary Part 3: terms relating to external orthoses. ISO 8549/3. Geneva, Switzerland: ISO, P age
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