A qualitative study to explore the impact of foot ulceration on health-related quality of life in patients with rheumatoid arthritis

BACKGROUND: The overall prevalence of foot ulceration occurring in patients with rheumatoid arthritis is estimated at 10-13% in the UK, with a high rate of recurrence. In contrast with diabetes, there has been a lack of research in this area and the impact of the problem from a patient perspective is poorly understood.

OBJECTIVE: To explore the added impact of foot ulceration on health-related quality of life in non-diabetic patients with rheumatoid arthritis.

DESIGN: Qualitative research design to elicit patient experiences.

SETTINGS: Participants were recruited from hospital and community podiatry clinics in West Yorkshire (UK) between May 2008 and June 2009.

PARTICIPANTS: A purposive sample of 23 adults with RA and open foot ulceration; patients with diabetes were excluded.

METHODS: In-depth interviews were conducted with 23 participants using a topic guide. Framework analysis was employed to facilitate a case and theme based approach to identifying descriptive and explanatory accounts of the impact of foot ulceration on health-related quality of life.

RESULTS: Participants indicated that foot ulceration impacted on their health-related quality of life across physical, social and psychological domains. Pain attributed to the ulcer was linked to new walking disability, affecting participants' lives in every domain. Pain and walking disability added to existing limitations in undertaking household tasks and personal care independently. Keeping the ulcer dry was a major problem for many in relation to personal hygiene. Participants described new restrictions in leisure activities which reduced social participation. Increased footwear/clothing restrictions affected self esteem and altered body image. An economic cost was attached to wound care and footwear alterations. Low mood, anxiety, frustration were attributed to the added impact of foot ulceration on their lives. Perceptions of impact fluctuated over time in relation to physical symptoms experienced by participants and the additional social limitations posed by the ulcer.

CONCLUSION: Foot ulceration has an additional impact on health-related quality of life over and above the impact of rheumatoid arthritis in every domain. Whilst prevention is the ultimate goal, high rates of recurrence mean that clinicians need to consider ways to improve quality of life for affected patients throughout the patient journey.