Importance of Therapeutic footwear

  • Prevalence of foot involvement in people with Rheumatoid Arthritis is as high as 90%
    • Even in remission over 70% complain of foot pain
    • Grondal L, Tengstrand B, Nordmark B, Wretenberg P, Stark A.The foot: still the most important reason for walking incapacity in rheumatoid arthritis: distribution of symptomatic joints in 1,000 RA patients. Acta Orthop. 2008 Apr;79(2):257-61.

  • Therapeutic footwear
    • Reduces pain,
    • Increases mobility
    • reduces the need for inappropriate interventions
    • Williams A.E, Rome K and Nester C.J. A clinical trial of specialist footwear for patients with rheumatoid arthritis. Rheumatology 2007 46(2):302-307


  • 15% - 25% chance of developing a diabetic foot ulcer during their lifetime

  • 50% to 70% recurrence rate over the ensuing 5 years.

  • Around 6,000 people with diabetes have leg, foot or toe amputations each year in England.

  • Lowers incidence of foot re-ulceration in patients with diabetes


  • NHS spends around £100 million on orthotics annually

  • Around 10% of this is footwear.

  • That means the NHS spends around £10 million each year.

  • It is estimated that one third of all footwear supplied through the NHS is either never worn or is discarded after little or no use.

  • Around £3.3 million each year is wasted.


  • Compliance – passive ‘do as I say’ – is this bad??

  • Concordance - about the relationship

  • Usability – product focussed

  • Effectiveness - Achievement of goals: being able to walk supermarket without pain.

  • Efficiency - Effort that is needed to achieve effectiveness putting on and taking off shoes.

  • Satisfaction - in a specified context of use


There are reported varying degrees of patient dissatisfaction due to:

  • Appearance
  • Heaviness
  • Poor fit

Resulting in it being used selectively or ending up as ‘shoes in the cupboard‘

Salford Report 1992

  • Described NHS orthotic services as a ‘Cinderella service’ and ‘… rudderless.. with … informed management, service audit and strategic planning having little place .’

  • 1 in 6 not worn

  • Service model not effective > MDT

Non-Compliance Reports

  • Audit commission 2000
  • emPOWER and the Limbless Association 2000
  • Audit Commission 2002
  • Audit Commission 2004
  • NHS PASA Orthotic Pathfinder 2004
  • NE Orthotic Good Practice 2004
  • Scottish Orthotic Services Review 2005
  • If the Shoe Fits -The Cordwainer 2007
  • West Midlands Orthotic project 2007
  • Hutton Report - York Health Economics Consortium: University of York 2009
  • Report for the British Healthcare Trades Association (BHTA) 2011
  • Arthritis Research UK 2012

Non-Compliance Problems

  • Poor recognition at higher management level

  • Poor leadership and management

  • Lack of recognition of the service and the focus being on ‘product’

  • Poor funding – fragmented through several departments

  • Lack of training for all involved in provision

  • Lack of specialist trained technicians for complex cases

  • Poor referral pathways

  • Lack of care pathways and involvement of other services for complex cases

  • Lack of patient involvement in service specification

  • Lack of patient input in outcome measurement

  • Lack of audit using metrics that reflect the value to the patient and the impact on their lives

  • Follow-up and review not built into the contract

  • Poor choice of product (dictated by single contract)

  • Poor information for patients

A clinical trial of specialist footwear for patients with rheumatoid arthritis

Qualitative Approach

  • Useful
    • new areas
    • when questions not answered by other approaches
    • new perspective

  • Recognises the participants (patients) ability to observe, reflect and analyse their own feelings and behaviour

  • Fits with NHS agenda to ‘hear’ the patients voice

  • Kant (1781) – “…cannot be objective about subjective matter”.


The Impact of feet affected by RA

  • “…..well it shows in your face…the pain you know…maybe because you are stood on them…makes you self conscious as well…I look and feel like an old lady”. Rose (UK)

  • “I feel awful and most of the time I feel bad about my appearance … I don’t feel feminine any more…my feet…well I don’t show them…hide them as much as possible…I get sad when I see women with straight toes and well manicured nails and I think my husband will not like me any more…”. Catalina (Spain)

  • “ … I don’t care about what people say now … in fact I think other people have got used to my arthritis… only the grandchildren pass comments about my toes not being straight” Hanne NL

The referring practitioners approach

  • “My Rheumatologist was… well… understanding my problem very well. In the hospital they took some pictures of her feet and these were examined thoroughly to decide what would be the solution for the foot pain.” Odette (NL)

  • “..I had an idea what the shoes would be like…he (the rheumatologist) told me …even had pictures of them …I didn’t feel a problem when I said no to the shoes …I think he understood the issues …I am a smart lady…and he complemented me on that…” Reina (SP)

  • “ I would have liked more choice as to whether to have the footwear in the first place… I felt I didn’t have time to consider whether I wanted it or not….just….well…went along with what the doctor said”. Daisy (UK)

The dispensing practitioners approach

  • “I think generally there is not much understanding about how rheumatoid arthritis affects the person…well…we are people aren’t we ….we are just not a pair of feet we have feeling… and sometimes I feel that they (practitioners) don’t understand…that makes me angry.”. Alison (UK)

  • “He pulled a face when he saw my feet….that made me feel… I was being difficult …I cried when I got home… very upset”. Sierra (SP)

  • The person who helped was very kind and understood the foot problems. He also explained what he was doing all the time … Every choice he had to make was reasoned out….this felt very good “. Femke (NL)

  • “They helped her in a professional and cool way, which was OK to her. However, she had a strange feeling when she left, because she was middle in the process of acceptance.” Sierra (SP)

  • “I was told to call them if I have problems with the shoes. I don’t like complaining … not my character…I am afraid that they think… she is complaining too much” Maud (UK)

The visibility of the footwear

  • “ I am not really bothered about how they look as my feet have less pain and I am very happy about that “ Hilda (UK)

  • “ Make me feel big and that everyone is looking… I hide them when I can …under a table…I really hate them but if I don’t wear them…well…I just wouldn’t go out….” Eda (NL)

  • “…while wearing this footwear your illness becomes the area for attention… I don’t deny my illness, but I don’t want my illness to become me …it takes a lot of things away from you. To be provided with orthopaedic shoes was the last step though.” Yvonne (UK)

The visibility of the footwear

  • “I can’t complain as I feel my mobility would not be as good with out these…Its important to be mobile and pain free…on a day to day basis they are just about ok…but when I go out I wear other shoes then pay for it after.” Rose (UK)

  • “Don’t go out much but sometime makes me feel like crying and I panic when I do get an invite… I think oh gosh these boots….I was invited to a wedding and just sat at home and cried”. Lena (UK)

  • “ I cant and wont wear these in the summer… its just too hot… I don’t do out at all if my feet are bad rather than wearing these…” Margarita (SP)

Footwear influencing social participation and activity

  • “I felt very tearful the first time I had the shoes…and in shame…I didn’t go out.. I tried them with my clothes and I looked untidy…not smart like my friends” Nadia (NL)

  • “ I cant wear these to the gym I would look ridiculous – I have stopped going and that’s not good for my joints and now I cant keep up with my friend” Juliana (SP)

“Wishes for improving my experience…”

  • “…I wish …
    • …for the choice whether to have them in the first place
    • …to choose shoes as any woman would – not just from pictures
    • …I knew that the practitioners listened to me
    • …I knew if the practitioners understood
    • …I had a follow up appointment
    • …for a variety of shoes for different purposes…”

- Practitioners opinions

  • Lack of time to assess patients needs other than the medical problem.

  • Consider that females with RA are very difficult to please aesthetically due to foot deformity

  • Lack of choice for them – feel obliged to do something

  • Not feeling part of the ‘team’ and therefore options not known

  • Lack of training in consultation styles

People’s Perceptions of Therapeutic Footwear

  • TFW is unique as a health intervention in that it -
    • fulfils a social as well as a clinical role
    • replaces something that is normally worn
    • removes the choice which is normally associated with an item of clothing.

Challenges with Qualitative research

  • Subjectivity – make subjective decisions in all research methods

  • Bias - Preconceived ideas of the researcher – dealt with by being transparent/ reflective

  • Social desirability response – any different from quantitative?

  • Lack of generalisability - low numbers? / Purpose of the research

  • Terminology different

    • Validity - Credibility or truthfulness (honesty about the research and extracts from text)

    • Reliability – Dependability (method of data collection and analysis)

    • Generalisability - Transferability


  • The evidence suggests that if used, footwear can improve symptoms and prevent re-ulceration (assume first ulceration).

  • However, this is in a defined and time limited context and in most studies with ‘compliant’ participants.

  • Patient compliance with footwear is variable and dependent on all the factors that influence everyone’s footwear choice plus in the context of TFW – time to accept, expectations and choice whether to have them or not.

  • Clinicians need to acknowledge that TFW is unique as a health intervention

  • Qualitative research methods can effectively reveal perspectives that are missed using quantitative methods