What outcomes matter to patients with foot and ankle disorders in rheumatic and musculoskeletal diseases? Findings from a qualitative synthesis and scoping review of the literature

Chapman, L.; Flurey, C.; Redmond, A.; Richards, P.; Hofstetter, C.; Tapster, B.; Emmel, J.; Helliwell, P.; Menz, H.; Marian, H.; Shea, B.; Siddle, H.J.

Abstract

Background
Foot and ankle involvement is common and debilitating in rheumatic and musculoskeletal diseases (RMDs), but outcomes in research and clinical practice are often inconsistently measured and may not be meaningful to patients. Outcome inconsistency contributes to lack of high-quality evidence to determine the effectiveness of foot and ankle treatments [1].

Objectives
To understand what outcomes are important to patients living with foot and ankle disorders in RMDs through an exploration of symptoms and impact, and to establish how these compare to outcomes measured in existing research studies.

Methods
A qualitative systematic review of interview and focus group studies involving patients with foot and ankle disorders in RMDs (inflammatory arthritis, osteoarthritis, crystal arthropathies, connective tissue diseases and musculoskeletal conditions in the absence of systemic disease) was undertaken. A scoping review of clinical trials and observational studies comparing conservative, pharmacological or surgical interventions for these disorders was also performed. Seven databases (Ovid Embase; Ovid MEDLINE; CINAHL; Psycinfo; Cochrane Database of Systematic Reviews; CENTRAL; PEDro) were searched from inception to March 2022. All data from the results sections of qualitative studies were extracted, coded and synthesised to develop themes, whilst outcomes measured in quantitative studies were extracted and tabulated. Confidence in the qualitative findings was assessed using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach, incorporating Critical Appraisal Skills Programme quality appraisal [2]. Patient and public involvement contributors were involved throughout both reviews, in the design, analyses and discussions about the findings.

Results
Thirty-four studies were included in the qualitative review, whilst 150 studies (n=83 randomised trials) were included in the scoping review. The majority of studies included patients with foot and ankle disorders in rheumatoid arthritis (n=18 qualitative studies, n=43 quantitative studies) or osteoarthritis (n=5 qualitative, n=96 quantitative). Six themes were generated from the qualitative synthesis: pain, change in appearance, activity limitations, social isolation, work disruption and emotional distress. Themes were closely related; foot/ankle pain and appearance changes (e.g. deformity and subsequent limitations in footwear and clothing) affected emotions and led to restrictions in physical, social and work activities, which caused further distress. Based on grading of the evidence, we had moderate confidence that most of the review findings represented the experiences of patients with foot and ankle disorders in RMDs. Foot/ankle pain (n=117 studies) and foot/ankle function (n=102 studies) were the most commonly measured outcomes identified in the scoping review; social function, occupational function and emotional status were rarely reported.

Conclusion
This is the first study to explore patients' experiences of foot and ankle disorders in RMDs alongside outcomes currently measured by clinicians and researchers. Our findings highlight that these disorders impact on multiple areas of patients' lives, both physically and psychologically. Pain was the predominant symptom experienced by patients and the most commonly measured outcome in existing research, but other outcomes that are important to patients should not be overlooked by clinicians and researchers. Our findings can guide patient-centred care and measurement of outcomes within clinical practice and future research.

References
[1] Edwards K et al. Evidence for current recommendations concerning the management of foot health for people with chronic long-term conditions: a systematic review. J Foot Ankle Res. 2017;10:51
[2] Lewin S et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series. Implementation Science. 2018;13(1):2

Acknowledgements:
NIL.

Disclosure of Interests
None Declared.

• Presentation Conference Type: Conference Abstract
• Conference Name: EULAR
• Start Date: Jun 12, 2024
• End Date: Jun 15, 2024
• Acceptance Date: Apr 1, 2024
• Online Publication Date: May 30, 2023
• Publication Date: Aug 17, 2023
• Deposit Date: Jan 16, 2025
• Journal: Annals of the Rheumatic Diseases
• Print ISSN: 0003-4967
• Electronic ISSN: 1468-2060
• Publisher: BMJ Publishing Group
• Peer Reviewed: Peer Reviewed
• Volume: 82
• Pages: 930-931
• DOI: https://doi.org/10.1136/annrheumdis-2023-eular.5474
• Public URL: https://uwe-repository.worktribe.com/output/13609905