Lake Louise, Alberta—A clearer picture is emerging of evidence-based, nondrug treatments for patients with juvenile idiopathic arthritis (JIA), thanks to a recent article on foot care for youth suffering from the common chronic condition—which is associated with pain, deformities, and malalignment in the feet—published online ahead of print.1Members of the Ottawa Panel determined that custom-made, semirigid foot orthotics and prefabricated shoe inserts significantly reduce pain intensity, activity limitation, foot pain, and disability.2 Supportive athletic shoes do not produce an appreciable benefit, according to the analysis.
The team published the results, and also presented them in poster form at the 2016 Canadian Rheumatology Association Annual Scientific Meeting.
Lead author Lucie Brosseau, PhD, Professor, University of Ottawa, Ontario, Canada, and colleagues first conducted a systematic critical appraisal of clinical practice guidelines in patients with JIA using Cochrane Collaboration methodology.1 They focused on the German Society for Pediatric Rheumatology, Royal Australian College of General Practitioners, and American College of Rheumatology guidelines. The team noted in their paper that, although the overall clinical practice guidelines were of high quality, the nonpharmacologic intervention recommendations were imprecise, and interventions varied between the clinical practice guidelines.
“Two of those 3 existing guidelines looked at non-pharmaceutical approaches. But the literature searches they performed on these nonpharmaceutical interventions were nonsystematic and the analyses were not quantitative, so the recommendations were not precise and not always based on randomized, controlled trials,” explained Dr Brosseau. “That’s why we decided to develop Ottawa Panel guidelines for the nonpharmaceutical management of [patients with] JIA.…But only the analyses on physical activity and orthosis have provided solid evidence of efficacy so far.”
Only 3 randomized controlled trials were of high enough quality to be included in the new detailed analysis.1 One of the studies randomized children to fitted foot orthoses, or 1-mm uncorrected leather boards; at 3 months, the comparison was statistically significant according to the investigators, but not according to the more stringent criteria applied by the Ottawa Panel. However, at 6 months the Ottawa Panel did find clinically important benefits in the same study in the form of pain reduction with fitted foot orthoses. Therefore, Dr Brosseau and colleagues recommended the use of custom-fitted, preformed foot orthotics for ≥6 months as an approach to reducing foot pain associated with JIA.
The second high-quality trial compared custom-fabricated, semirigid orthotics, prefabricated shoe inserts, and new athletic shoes with soles for 3 months. There was a clinical but not statistically significant reduction in pain intensity, activity limitation, foot pain, and disability at the end of the trial. This led the Ottawa Panel to suggest that these orthotics be used for ≥3 months by patients with JIA versus wearing new athletic shoes only.
The third trial included in the analysis allocated subjects to multidisciplinary versus standard foot care. At the end of the 6-month intervention, there was no clinical benefit from multidisciplinary foot care. Therefore, the Ottawa Panel does not recommend this approach for patients with JIA.Dr Brosseau and colleagues seem to be gaining momentum in their search for more information regarding the often overlooked use of nonpharmaceutical interventions for many aspects of rheumatic diseases, despite the challenges of finding funding for this work.
“We are now conducting [a randomized control trial] in nonpharmaceutical interventions in rheumatic diseases to enrich the literature in this area,” Dr Brosseau said.
- Brosseau L, Wells G, Smith C, et al. Ottawa Panel evidence-based clinical practice guidelines for foot care in the management of juvenile idiopathic arthritis. Arch Phys Med Rehabil. 2015 Dec 18. Epub ahead of print.
- Brosseau L, Wells G, Smith C, et al. Ottawa Panel evidence-based clinical practice guidelines for foot care in the management of juvenile idiopathic arthritis. Poster presented at: 2016 Canadian Rheumatology Association Annual Scientific Meeting; February 17-20, 2016; Lake Louise, Alberta.