Title: Tight control of inflammatory foot and ankle disease in patients with rheumatoid arthritis.
Funder: Health Education England

Abstract: BackgroundDisease-related foot pathology is well recognised as having a significant impact on mobility and functional capacity in the majority of patients with rheumatoid arthritis (RA) [1]. Over the past fifteen years, there has been a revolution in the management of RA, with the introduction of more aggressive drug therapies for the systemic disease management. In spite of these advances, early reports suggest that the frequency of foot involvement does not appear significantly reduced [2, 3]. The recent treat to target' paradigm of care for managing RA aims to achieve clinical disease remission and target treatment strategies at individual patients' disease activity[4]. However, patients in clinical remission still have evidence of active disease in weight-bearing joints [5, 6]. Importantly, there is no clear clinical pathway for podiatrists and rheumatologists to identify and manage residual inflammatory foot and ankle disease. Aims and plan of investigation This Clinical Lectureship proposes to establish a programme of work, which will adapt the formal medical paradigm treat to target' to facilitate a tight control' approach to assessing and treating persistent inflammatory foot and ankle disease in patients with RA, and develop a new imaging outcome measure.There are two objectives underpinning this clinical academic programme of work, which will include collaboration with key stakeholders in the rheumatology community and the international Outcome Measures in Rheumatology Clinical Trials (OMERACT) organisation. Objective 1 (Clinical work package): Develop a tight control clinical care pathway for persistent inflammatory foot and ankle disease in patients with RA deemed to have low stable clinical disease activity or be in clinical remission. Working with expert health professionals, professional bodies and patient representatives we will propose and develop a clinical care pathway to stratify the clinical assessment and management of persistent inflammatory foot and ankle disease in patients with RA. The clinical care pathway will be a practical tool for providers of foot health care in primary, secondary and tertiary care and designed to reflect varying levels of clinical specialist knowledge and experience. Objective 2 (Academic work package): Develop and validate an imaging outcome measure to quantify inflammatory foot and ankle disease in RA for use in clinical research and specialist practice. In collaboration with the OMERACT Ultrasound Task Force we will develop and test the reliability of a novel Foot and ankle Ultrasound Scoring System in Rheumatoid Arthritis (FUSS-RA). A multi-centre, cross-sectional study will be undertaken to determine the validity of the FUSS-RA and clinical care pathway against the gold standard' MRI in detecting inflammatory foot and ankle disease.Potential benefits to patients and the NHS The cost of foot pathology in RA is substantial: patients with RA and persistent foot symptoms frequently seek help from multiple health professionals on multiple occasions, often with limited success. The clinical care pathway will provide structured assessment and clinical intervention strategies for podiatrists and rheumatologists to ultimately improve their capacity and capability to achieve an optimal outcome for persistent inflammatory foot and ankle disease in patients with RA. This clinical and academic programme of work will adapt the formal medical treat to target' paradigm of care to provide a disease-specific, tight control clinical care pathway for managing persistent inflammatory foot and ankle disease in RA with the goal of achieving foot disease remission. The clinical care pathway will be implementable' immediately because of the clinical expertise and evidence-based principles that will have been applied in the development of this complex intervention.The FUSS-RA will provide an outcome measure for future clinical trials and will be useful as a measure of clinical improvement in specialist podiatry and rheumatology departments where ultrasound facilities are readily available.

Lay abstract: Foot problems are well recognised as having a significant impact on daily activities in the majority of people with rheumatoid arthritis (RA). Despite the introduction of targeted drug treatment for RA, symptoms and active disease persist in the feet. Patients with RA and persistent foot and ankle symptoms frequently seek help from multiple health professionals on multiple occasions, often with limited success. This research aims to develop a clinical care pathway and ultrasound assessment tool that will help podiatrists and rheumatologists systematically target any on-going foot pain and inflammation in people with RA, even if they have otherwise well-controlled RA.

Research activity codes: 4.1 DISCOVERY AND PRECLINICAL TESTING OF MARKERS AND TECHNOLOGIES;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: INFLAMMATORY AND IMMUNE SYSTEM